Cross Connection Survey
This survey is distributed to all Cascadia Water customers so that we can inventory areas that are a potential
cross connection hazard to you and your community as per Department of Health WAC # 246-290-490. Please
take a moment to complete this questionnaire and return it to us, either by mail or email, at your earliest
convenience. If you are a tenant and unable to complete, please forward this on to the property owner. It is
imperative that we receive a response from you, (even if all your answers below are “NO”).
If you already have a backflow device installed at this time, please include a copy of the latest test results with
your survey so our records can be updated and include the name of the individual who installed the device and
who last tested it.
Please fill out the survey to the best of your ability. Thank you.