City of Peru Commercial Cross Connection Control Survey

City of Peru Commercial Cross Connection Control Survey
Business Name*
Address Number*
Street Name*
Email*
example@example.com
Do you have any other sources of water, such as a private well or tank that is connected to the water system?

WellPondLakeTankI Don't Know
Are there any backflow devices installed on the premises*
Has the device been tested?*
What type of water service line do you have coming into your Business? (Service line before the water meter)*
Take a photo of your meter and service line.
What type of water lines do you have running throughout your Business?*

GalvanizedPlasticCopperLeadI Don't Know
Do you have a sump pump or downspouts connected to the sewer system?*
Does your business have any of the following equipment installed? Mark all that apply.

Fire Sprinkler SystemHot water heat or boilerWater cooling tank or evaporatorTemporary water serviceTruck or tank filling equipmentWater cooled equipmentPressure washerSoap injectorSwimming poolIndustrial fluid systemSteam equipmentCar wash facilitiesSoft drink dispenserChemical feederPressure boosterSterilizerEmbalmingIndustrial air conditioning equipmentBaptismal fountain or tubIn-ground sprinkler systemShampoo bowlYard hydrantAir washerCondenser washerGrease trapsAir gapWater softener
Enter any other equipment that is in use but not listed above.
Next steps after survey completion:

The water system is required by the EPA to have a Cross Connection Control Program in place. Part of the program is a mandatory Tri-Annual Cross Connection Control Survey. This survey must be filled out by all residents and businesses connected to the water system.

If you do have a backflow prevention device installed it has to be tested/inspected annually by a plumber with a backflow prevention certification.
Should be Empty: