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Cross Connection Control Survey

  1. Do You Own The Property?*
  2. Please Include Name, Phone, Email

  3. Type of Service:*

    Check any that apply

  4. Indicate which of the following are used at this service address.*

    Check all that apply

  5. Have any of these items been installed on your property in the past 12 months?*
  6. Water Meter Size*

    Select any that apply if you have multiple

  7. Service Line Material*

    Private Side - From City Right of Way to Dwelling

  8. Do you have a testable backflow preventor on your property?*
  9. Have any changes been made to your water plumbing in the past 5 years?*
  10. To the best of your knowledge has the City of Avon Utilities Department ever conducted an onsite backflow survey of your property?*
  11. I hereby certify that I am the owner of the above listed property or am authorized to act on behalf of the owner and that all information provided is true, complete, and correct to the best of my knowledge.*
  12. Leave This Blank:

  13. This field is not part of the form submission.