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.

    First Name

    Last Name

    Date

    Phone Number

    Service Address

    Do you have any of the following? Please select the appropriate answer.
    __________________________________________________________________________________________________

    Additional source of water (i.e. private well, irrigation system, other water system)
    YesNo

    Hot tub or Jacuzzi
    YesNo

    Swimming pool
    YesNo

    Underground sprinkler system
    YesNo

    Above-ground irrigation system (i.e. drip irrigation or misting heads)
    YesNo

    Greenhouse
    YesNo

    Any utility sink with a threaded faucet (in house, garage, etc)
    YesNo

    Evaporative/Swamp cooler
    YesNo

    Fire sprinkler system
    YesNo

    Unidentifiable piping
    YesNo

    Heating system that integrates boilers or hot water piping
    YesNo

    Do you use any of the following at your premise? Please select the appropriate answer:
    __________________________________________________________________________________________________

    Antifreeze flush kits
    YesNo

    Pesticide of herbicide sprayers that attach to a garden hose
    YesNo

    Darkroom equipment
    YesNo

    Portable dialysis machine
    YesNo

    Do you have a bathtub that does not have an air gap (unobstructed vertical space) between the faucet and the tub when filling?
    YesNo

    Do you have a water softener or any other treatment system connected to your water supply?
    YesNo

    Do you have an auxiliary water supply on your premise?
    YesNo

    Do you have a water trough for livestock?
    YesNo

    Do you pump water from any creeks or wells on your property?
    YesNo

    Do you have a booster pump system to increase your water pressure?
    YesNo

    Do you have a backflow prevention device on your property now?
    YesNo

    Do you have any other water-using equipment on your property that you are aware of that could create a cross connection? (i.e. water bed, fish pond)
    YesNo

    Other Cross Connections:


    Please write your signature in the box below (required)