Cross-Connection Control Survey Form
Nebraska's Safe Drinking Water Act requires public water systems to implement an on-going cross connection control program. An important part of this program is public education. It is believed that a well-informed public will be more aware of the possibility of cross connections within their property and will take reasonable and sensible precautions to avoid creating cross connections on their property.
Email address *
Name (Last, First): *
Your answer
Business Name (if applicable):
Your answer
Address: *
Your answer
Account Number: *
Your Account Number is shown on your utility bill or you may contact City Hall at 402-694-6992 for assistance.
Your answer
Is this a Commercial or Residential water service? *
Is there an underground lawn irrigation system installed and/or in use? *
Is there a water softener installed and/or in use? *
Is there a private well located and/or in use on this property? *
Is there a swimming pool or hot tub installed and/or in use? *
I have completed the above survey truthfully and to the best of my knowledge listed all water uses at my facility that could potentially create a hazard to the public water supply. *
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