Cross Connection Control Survey
IMPORTANT - PLEASE COMPLY
Water Use Survey - Cross Connection Control Program
Per the OEPA, we are required to perform a “survey” of all water customers
every few years to help protect the public water systems. This survey is
required by the OEPA and is not optional.
THANK YOU for your cooperation and assistance in keeping our water safe!
Items marked with a red asterisk are required fields.

Please note: The owner of the property is responsible to have all backflow prevention devices inspected
every twelve months. Failure to do this may result in your water service being turned off. If more
information is needed, please call Wooster Water Utilities at 330-263-5284.
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Email *
Service Address *
Business Name (If applicable):
Property Owner's Name *
Property Owner's Phone Number *
Owner's Address (if different than service address)
Type of Service *
Indicate which of the following will be used at the service address:  (Please check all that apply)
Please Check all that apply
Underground Sprinklers
Auxiliary water Systems (Private Wells, etc.)
Water recirculating systems and pumps
Utility sink with threaded faucet
Hot water or steam boilers
Water trough for livestock
Portable dialysis machine
Insecticide sprayer's (Attached to garden hose)
Swimming Pool
Jacuzzi
Greeenhouse
Waterbed
Metal processing
Antifreeze flush kits
Booster pump
Hot Tub
Laboratories
Solar heating system
Fire sprinkler
Water Softener
Darkroom equipment
Water Powered Sump Pump Backup
Other (See other question below)
None of the above
Do you have a backflow preventer on your property now? *
Required
If you answered other in the items list above please list the other water-using equipment on your property which was not mentioned above.
Have you installed any of the items listed in the checkboxes above on your premises in the last 12 Months? *
Required
If yes to the question above please explain.
Please describe, if any, changes in water use practices in the past 5 years. *
Name of person completing form *
Address of person completing form (if same as above enter same) *
Phone number of person completing form (if same as above enter same) *
I hereby certify that I am acting as agent for the owner of the property listed that all information provided is true, complete and correct. *
Required
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