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2. Residential Cross-Connection Questionnaire
3. 
5. Name*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Fax Number
19. Questionnaire
21. Cross Connections Program Link
    Click Here
23. Do you have a sprinkler system?

    1. Yes
    2. No
    3. Unsure
24. Has the PVB (pressure vacuum breaker) been tested?

    1. Yes
    2. No
    3. Unsure

    If NO, see city website for information on hot to get my back flow device tested.
26. Does hose bibbs have vacuum breakers?

    1. Yes
    2. No
    3. Unsure
27. Do you have a water assisted sump pump backup?

    1. Yes
    2. No
    3. Unsure
29. Do you have a boiler heating system?

    1. Yes
    2. No
    3. Unsure
30. Do you own the home?

    1. Yes
    2. No
    3. Unsure
32. Is there a private well?

    1. Yes
    2. No
    3. Unsure
33. Service line material

    1. Plastic
    2. Galvanized
    3. Unknown

    1. Lead
    2. Copper
    3. N/A

    See city website on information on how to ID a service line.
35. The City of Taylor will be contacting you to set up an appointment.
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field