Section 1 of 7 in this document
image

Commercial Cross-Connection Control Backflow Survey

The Village of Schaumburg is dedicated to delivering safe and clean drinking water to your business. An important part of this is ensuring the effective control of cross-connections. A cross-connection is a point where your water supply pipe comes into contact with a source that could contaminate water. Lawn irrigation systems, fire sprinklers, hot tubs/spas and in ground pools are examples of potential cross-connections. If left unprotected, cross connections may allow contaminants or pollutants to enter the water system through a backflow. Backflows occurs when a drop in water pressure causes water to flow in the opposite direction, increasing the potential for contaminated water to flow back into the system.

To ensure the integrity of the water supply, the village has an established Cross-Connection Control program in compliance with Illinois Environmental Protection Agency (IEPA) requirements. A component of this program is a triennial survey of village properties to ensure potential cross-connections and backflows aren't present.

Your participation in a voluntary survey of your property will help determine where cross-connections may exist. Thank you in advance for your assistance.

This survey will assist to help prevent the contamination or pollution of our water resources. Please complete the form below to the best of your ability or consult a licensed plumber for assistance.

Property Address

Is your Property and Mailing Address the same?

Mailing Address

Building Owner Information

Rich Text Here

Is the Person Responsible for Device Maintenance and Building Owner the same?

Person Responsible for Device Maintenance

Section 2 of 7 in this document

System Information

Check all items that are at your property.

Does your business use chemicals, such as a medical facility or a beauty salon?

Do you have any equipment hooked directly to your waterlines?

Are there any backflow assemblies present at your property?

Section 3 of 7 in this document

Device Manufacturer Information

Fire Sprinkler System

Lawn Irrigation System

X-Ray Machine

Large, Commercial Boiler (not a water heater)

Commercial Ice Maker

Swimming Pool

Cooling Tower

Hose Aspirator for Spraying Chemicals

Medical Equipment

Farm Equipment

Photo Lab

Water Tank Truck Filling Station

Section 4 of 7 in this document

Do you need to add additional devices?

Section 5 of 7 in this document

Enter additional devices below.

Section 6 of 7 in this document

Sign Here

Sign Here
Choose how to sign