The Illinois Environmental Protection Agency (IEPA) requires that all water suppliers in the State of Illinois have an effective Cross Connection Control / Backflow Prevention Program. The purpose of the program is to protect public health and to protect our public water supply by preventing backflow of contaminants back into the potable water system. More information on the Village’s Cross Connection Program, can be found on the Village’s website at http://www.lagrangeil.gov/crossconnection.

One requirement of the program is to send a biennial cross connection survey to all water customers. The purpose of the survey is to update existing inventory of cross connection devices and to determine if other cross connection devices exist. Below is a survey that we are requesting you complete and submit to the Village. If you have any questions related to the program or this survey, please contact Russell Davenport, Assistant Director of Public Works at (708) 579-2328. Thank you for your cooperation.

CUSTOMER INFORMATION

Account Number

Name *

Address*

Phone Number*

E-mail Address*

WATER USE SURVEY

Property Classification*

Commercial Residential

What is your specific type of use? (house, office, retail, restaurant, car wash, etc.)
*

Do you have an underground lawn sprinkler system?*

No

Yes

Do you have a fire sprinkler system?*

No

Yes

Do you have an auxiliary water source (i.e. well) at your location?*

No

Yes

Does your business use any type of chemicals?*

No

Yes

Do you have any of the equipment listed below? (Please check all that apply.)

Boiler System (Excluding hot water heaters) Chemical Feed Equipment Food Processing Equipment Garden Hose Attachments Laboratory Equipment Medical Equipment Ornamental Fountains Outdoor Hose Bibs Pedicure Station

Photo Developing Equipment Shampoo Bowl Soft Drink Dispenser Solar Heat Systems Swimming Pool and/or Spa Sump Pump Wash Basins and Service Sinks Water-Cooled A/C or Chiller Water Softner

Are there any backflow preventers at your site?*

No

Yes

If yes, please provide the following information:

Manufacturer:

Model:

Serial #:

Size:

Connected To:

Additional Backflow Preventer Devices: