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Cross-Connection Control Program - Survey Questionnaire

  1. See cover letter.
  2. PLEASE NOTE:
    The return of a survey questionnaire without the company name, date, address, telephone number and account number, or the failure to answer all questions pertaining to your facility, may result in an on-site inspection by the City of Hot Springs.
  3. Type of Business*
    Check all that apply.
  4. Please specify the type of facility not mentioned above.
  5. Is there a Backflow Preventer (Reduced Pressure Zone Assembly) installed on this building's water service line?
    Please answer the following questions.
  6. Please specify the amount of floors not mentioned above.
  7. Does Your Facility Contain Any of the Following?
    Check all that apply.
  8. Please list the Boiler types mentioned above.
  9. Please list the Chemical types mentioned above.
  10. Please list the Commercial Laundry types mentioned above.
  11. Please list the Equipment types mentioned above.
  12. Please list other items not mentioned above.
  13. Select Your Type of Facility
  14. List all equipment using water at this facility
    Please list all information pertinent to the following, including: materials stored/used and building tenants
  15. Facility
  16. Leave This Blank:

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