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Welcome to the City of Papillion, NE, Mayor's Hotline
Today is Tuesday, May 30, 2017.
Cross-Connection Questionnaire

Nebraska Department of Health and Human Services Title 179 requires the completion of a Cross-Connection Survey for all water connections to a public water system every five years. We ask for your assistance in completing this survey. To meet the state requirements, City of Papillion water customers must return 100% of all surveys. Please complete the following questionnaire by November 16, 2015. If you need assistance in filling out this form, or if you have any questions about cross connections, please call 402-597-2043. Thank you for your cooperation.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
Email:
Daytime Phone: (
Fax: (
* Address:
City:
State:
ZIP:

* Do you have a private well or other alternative source of water?



 
If yes, is the water well connected to the same plumbing system as the water supply?



 
If yes, is it protected by a testable backflow device?



 
* Do you have a swimming pool or hot tub?



 
If you fill it with a hose, does a hose bib vacuum breaker protect it?



 
If you fill it with a direct line, is it protected by a reduced pressure backflow preventer?



 
* Do you have a lawn sprinkler system?



 
If yes, it is protected by a testable backflow device?



 
* Do you have a hot water/steam boiler (not a water heater)?



 
If yes, is it protected by a testable backflow device?



 
Are chemicals used in the water?



 
If yes, please list chemicals:
 
* Do you have a cooling tower?



 
If yes, is it protected by a testable backflow device?



 
Are chemicals used in the water?



 
If yes, please list chemicals:
 
* Do you have any biological, veterinary, photo, chemical, or medical labs/facilities at this address?



 
If yes, is it protected by a testable backflow device?



 
* Do you use a hose aspirator for spraying chemicals? (All hose connections should have a hose bib vacuum breaker.)



 
If yes, is it protected by a hose bib vacuum breaker?



 
* Do you have a fire suppression system?



 
If yes, is it protected by a testable backflow device?



 
* Do you have a water truck or tank water filling station or pipe?



 
If yes, is it protected by a testable backflow device?



 
Are there chemicals used in the water?



 
If yes, please list chemicals:
 
* Do you have a water-cooled compressor?



 
If yes, is it protected by a testable backflow device?



 
* Do you have a post mix water carbonator?



 
If yes, is it protected by a testable backflow device?



 
* Do you have an ice machine?



 
If yes, is it the compressor water cooled?



 
If yes, is it protected by a testable backflow device?



 
* Are there any pumps hooked to the plumbing?



 
If yes, please check all that apply:




5
 
If other, please list:
 
* Please list all other water processes connected to the water piping, or type N/A:
 
Check here to have email confirmation of this submission.

* Information is required.

Notes:

If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.

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