Fillable Customer Information City of Decatur / Department of (City of Decatur Illinois)

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Customer Information City of Decatur / Department of (City of Decatur Illinois)

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U.S.A. forms for City of Decatur Illinois

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COMMERCIAL CROSS CONNECTION SURVEY
City of Decatur / Department of Public Works
WATER SERVICES DIVISION
# 1 Gary K. Anderson Plaza Decatur, IL. 62523
Customer / Business Name
Water Customer Address
Account#
Degreasing Equipment
Ice Maker
Deep Utility Sink with Hose
Carbonated Beverage MachineElectric Dish Washer
Condensate Tanks
Make-up TanksWater Purifier
Water Softener
Boiler Heating System
Customer Information
Please Fill Out The Information Below / Check All That Apply
Phone # Date of Survey Name of Person Completing Survey
Whirlpool / Hot Tub
High Pressure Washers
Lawn Irrigation System
Urinal / Flushometer
Washing Machine
Private Well / Cistern / Pond
Toilet / Flushometer
Dialysis Equipment
X-Ray Equipment
Please Indicate Type of Business
Yard Hydrant
Shower Sprayer with Hose
Dental Equipment / Cuspidors
Chemical Feed Equipment
Drinking Fountains
Fire Sprinkler System
Fertilizer Injection
Booster Pump
Film Processor
Car Washing Equipment
Water Treatment Filtration Systems
Commercial Cooking Kettles
Autoclave / Sterilizer
Outside Faucets
Building (3) Stories or More Labratory Equipment
Other:
SEE BACK
COMMERCIAL CROSS CONNECTION SURVEY
City of Decatur / Department of Public Works
WATER SERVICES DIVISION
# 1 Gary K. Anderson Plaza Decatur, IL. 62523
Other:
Thank You,
This survey will help prevent accidential contamination of our water system. Please return your
completed survey in the enclosed envelope. If you have any questions, please call Water Services at
875-5705.
Other:
Soap / Chemical Management System Shampoo Sink
Water for Manufacturing Process
Embalming Equipment
Food Waste Grinder w/Water Connection
Radiator Flushing Equipment
Sewer Connected Equipment / Flushing
Cooling Tower
Please Fill Out The Information Below / Check All That Apply
Aspirators / Medical Lab
Aspirators / Weedicide, Herbicde, PesticideSteam Generating Equipment
Humidifier w/ Water Connection
Other: Other:
THIS SECTION TO BE COMPLETED BY THE WATER SERVICES DIVISION
Serial Number Type Test Date Location
Backflow Information
Serial Number Type Test Date Location
Serial Number Type Test Date Location
Meter Information / Location
Comments
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Customer Information City of Decatur Department of (City of Decatur Illinois)

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Completed 15 February 2021

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