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Cross Connection Control Survey
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CROSS-CONNECTION CONTROL SURVEY
The following form is to be used by water department personnel and/or by customers of the Village of Rantoul public water supply. Data from this form may b used to determine if the property should be inspected by a licensed plumber with a CCCDI certification to detect and correct any cross-connections found on the property.
First Name
Last Name
Address1
City
State
Zip Code
Name/Title of Person Conducting Survey
Phone Number
Residential: (Check all that apply)
Kitchen:
Sink Faucet
Sink Faucet w/Sprayer
Ice Maker
Garbage Disposal
Comments
Bath:
Lavatory
Toilet
Bathtub
Hot Tub
Bidet
Comments
Other:
Boiler heat
How Many Boilers?
Exterior: (Check all that apply)
 
Outside Faucets
How Many?
Non-Freezing Type
How Many?
Lawn Irrigation System (Permanent)
Lawn Fertilizer System
Private Well(s)
Is/Are private well(s) physically connected to the water system?
Yes
No
Commercial: (Check all that apply)
Lavatory
How Many?
Deep Sinks
How Many?
Boilers
How Many?
Outside Faucets
How Many?
Lawn Irrigation (Potable)
How Many?
Lawn Irrigation System (Permanent)
How Many?
Mixing Tanks w/ Overhead Fill Line
How Many?
Mixing Tanks w/ Bottom
How Many?
Watering Troughs
How Many?
Bulk Water Salesman
How Many?
Water-Cooled Air Conditioning System
How Many?
Sitz Baths
How Many?
Fire Protection Systems: Embalming Facilities (Mortuaries)
How Many?
Private Well(s)
How Many?
Is/Are private well(s) physically connected to the water system?
Yes
No
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