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Welcome to the City of Papillion, NE, Mayor's Hotline
Today is Sunday, March 26, 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?
Yes
No
Don't Know
 
If yes, is the water well connected to the same plumbing system as the water supply?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you have a swimming pool or hot tub?
Yes
No
Don't Know
 
If you fill it with a hose, does a hose bib vacuum breaker protect it?
Yes
No
Don't Know
 
If you fill it with a direct line, is it protected by a reduced pressure backflow preventer?
Yes
No
Don't Know
 
* Do you have a lawn sprinkler system?
Yes
No
Don't Know
 
If yes, it is protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you have a hot water/steam boiler (not a water heater)?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
Are chemicals used in the water?
Yes
No
Don't Know
 
If yes, please list chemicals:
 
* Do you have a cooling tower?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
Are chemicals used in the water?
Yes
No
Don't Know
 
If yes, please list chemicals:
 
* Do you have any biological, veterinary, photo, chemical, or medical labs/facilities at this address?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you use a hose aspirator for spraying chemicals? (All hose connections should have a hose bib vacuum breaker.)
Yes
No
Don't Know
 
If yes, is it protected by a hose bib vacuum breaker?
Yes
No
Don't Know
 
* Do you have a fire suppression system?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you have a water truck or tank water filling station or pipe?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
Are there chemicals used in the water?
Yes
No
Don't Know
 
If yes, please list chemicals:
 
* Do you have a water-cooled compressor?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you have a post mix water carbonator?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Do you have an ice machine?
Yes
No
Don't Know
 
If yes, is it the compressor water cooled?
Yes
No
Don't Know
 
If yes, is it protected by a testable backflow device?
Yes
No
Don't Know
 
* Are there any pumps hooked to the plumbing?
Yes
No
Don't Know
 
If yes, please check all that apply:
Fountain
Pressure Booster
Sewer
Other
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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