Multi-Family Cross Connection Identification Survey Multi-Family Cross Connection Identification Survey Name on the Account * Required First Last Account Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account Number * RequiredThis number is located on the top right corner of the survey form enclosed in your letter. Occupancy * RequiredOwnRentChoose the location that your meter serves * RequiredHomesBuildings (garages, outbuildings, barns)How Many? * Required Which of the following do you have? Check all that apply * Required Underground Sprinkler System Drip/Soaker/Irrigation System Darkroom Equipment Commercial Dishwasher Chemical Feed System Well Pump RV Water Hookup Swimming Pool Chemical Irrigation System Fire Suppression System Water Softener/Reverse Osmosis Yard Hydrant Pressure Booster Pump RV Dump Station Hot Tub Solar System Portable Dialysis Machine Insecticide Sprayers Livestock Water Troughs Onsite Water Storage Tank Utility Sinks Boilers/Closed Loop Hot Water Heaters Soda Machine Cleaning Solution Dispenser Auxiliary Water Source (Well, Ditch/Canal) Ghost Pipes (Unknown Connection) Any Other Water Hookups Do you have outside hose bibs* at your buildings that are used for non-potable purposes? * RequiredYesNoHow Many? * Required * Colorado Plumbing Code may require that the hose bibs are protected. * While not required by CDPHE it is best industry practice is to protect with a vacuum breaker. Do you have a backflow protection device on your property now? * RequiredYesNoDo you have any water-using equipment not mentioned above? * RequiredYesNoPlease Describe * RequiredIf you marked or answered yes to any of the above are you aware of potential backflow prevention measures being practiced onsite, such as an air gap, check valve or backflow prevention assembly? If so please explain and include the location of the identified backflow prevention measure. If not, type N/A * RequiredSignature * Required AgreeBy checking this box and typing my name below I acknowledge that to the best of my knowledge the information provided is as accurate as possible.Name * Required First Last Phone * RequiredEmail * Required Please notify this office if any of the above conditions change.