Residential Cross-Connection Questionnaire
If you do not know what a hose bib vacuum breaker or what a Reduced pressure zone backflow assembly is please see attached video and flyers attached to the billing email.

Look over the plumbing in your home and your sprinkling system, read and answer every question to the best of your knowledge.

Mayfield Town has an active cross-connection control policy in place which directs us to survey all of our water customers annually, keep records of all tests on testable backflow preventers, and issue a reminder notice when testing is due.
The customer shall provide access for inspection and testing by water system personnel at all reasonable times to determine whether cross-connections, sanitary hazards or other violations of the water system ordinance or policy rules exist.
If you have a testable backflow preventer, you are required to have it tested annually by a certified technician. Copies of the test results must be sent to Mayfield town.

*IF YOU HAVE MULTIPLE CULINARY WATER CONNECTIONS IN MAYFIELD TOWN, Please complete this questionnaire for each property. Do not add multiple addresses to one questionnaire.

Thank you for helping Mayfield Town meet this State of Utah Regulation.

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Backflow 101, an Informational video on Backflow
What is your PHYSICAL address? *
Is there any other source of water, such as a private well, at this address?  (Not Mayfield Irrigation water) *
Do you have a swimming pool or hot tub? *
If you have a swimming pool or hot tub, do you fill it with a hose that has a hose bib vacuum breaker attached to it? *
If you fill your pool or hot tub with a direct water line is it protected by a reduced pressure backflow preventer? *
Do you have animals on the property that receive water in a trough or bucket? *
If you have a animal water trough, do you fill it with a hose that has a hose bib vacuum breaker attached to it? *
Do you have a lawn and or landscape sprinkler system?               (Not including sprinkler systems that can only be ran with irrigation water, please select yes if your system can be ran by both culinary and irrigation) *
Is your lawn and or landscape sprinkler system protected by an approved backflow preventer? (**See Below) *
To heat your home, do you have a hot water boiler or steam boiler? (Not a water heater) *
If you have a hot water boiler or steam boiler is it protected by a reduced pressure backflow preventer?(All boilers are required to have an RP) *
Do you have a photo lab, medical, biological, auto paint/repair, veterinarian or farm equipment, or any other chemical or medical labs or facilities at this address? *
Are any chemicals used in the water? *
If chemicals are used in the water, please list the chemicals:
Do you have any testable backflow preventers on your property? *
If you have a testable backflow preventer on your property, Has it been tested by a certified back flow tester this year (January 1st 2020-November 30th 2020) *
Do you have a hose aspirator for spraying chemicals? *
If you have a hose aspirator for spraying chemicals, is it protected by a hose bib vacuum breaker? (All hose connections should have a hose bib vacuum breaker) *
Please enter the date you completed this form *
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**Lawn sprinkler systems that use booster pumps or chemical injection systems MUST HAVE a backflow preventer installed which has to be tested every year. Please check the Mayfield Town Code, Utah drinking water rule R309-105(12), or the plumbing code and its amendments as adopted by the State of Utah for regulations.
Thank you. This survey will help prevent accidental contamination of our drinking water system. Any questions or concerns about cross connection contamination or backflow prevention can be directed to Mayfield town at 435-528-5061.
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