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Cross Connection Control Survey
The City of Hickory Hills (City) is responsible for delivering safe drinking water to the public. The City is required by the Illinois Environmental Protection Agency to survey all water services connected to our public drinking water supply by developing and implementing a backflow prevention program.
This program mandates that we survey all water customers to identify actual and potential cross connections that may exist at your home or business. A cross connection is a connection between a potable water supply and a non-potable source, where a contaminant potentially could enter the drinking water supply. You might know your backflow devices by their more common names of RPZ (Reduced Pressure zones) or DC (double check valves).
Your cooperation is essential. All water customers are required to complete and return this survey by paper or electronic form. The survey below should take less than 10 minutes of your time. Thank You.
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Today's Date
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MM
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DD
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YYYY
Name
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Your answer
Address
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Your answer
Telephone Number
Your answer
Please check the box(es) that best describes the use of water at your residence. (Check all that apply)
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Typical water usage such as cooking, drinking, bathrooms, household laundry, dish-washing appliances and outside water spigots.
Swimming Pool/Hot Tub - In Ground
Swimming Pool/Hot Tub - Above Ground
Hot Water Heat or Steam Boiler System
Fire Sprinkler Protection System
Lawn Sprinkler System
Private Well Connected to Water System
Water Booster Pump
Chemical Mixing Connected to Water System
Other:
Required
Do you have any backflow prevention devices installed on your plumbing system?
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Yes
No
I am unsure and would like a representative to contact me for further explanation.
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