Commercial Cross Connection Plumbing Survey

Please complete all fields and press "Submit" when complete.

If you have questions please contact 402-441-5912, or email at ctaylor@lincoln.ne.gov. Thank you for assisting in compliance with State of Nebraska public water supply regulations and protecting Lincoln's drinking water.

Company Information

Contact Person

Please complete survey even if no cross connections are present.

Plumbing Cross Connection Type Is connection present? Is connection protected with backflow?
1.Auxiliary water source water such as a well used for irrigation
Is connection present?
Is connection protected with backflow?
2.Auxiliary water source used for geothermal heating or cooling
Is connection present?
Is connection protected with backflow?
3.Underground lawn irrigation system at this address
Is connection present?
Is connection protected with backflow?
4.Lawn irrigation system using chemicals, fertilizer, or has a booster pump
Is connection present?
Is connection protected with backflow?
5.Swimming pool or hot tub at this address
Is connection present?
Is connection protected with backflow?
6.Cooling tower
Is connection present?
Is connection protected with backflow?
7.Boiler or steam system
Is connection present?
Is connection protected with backflow?
8.Water cooled compressors
Is connection present?
Is connection protected with backflow?
9.Fire suppression system
Is connection present?
Is connection protected with backflow?
10.Post mixed carbonator
Is connection present?
Is connection protected with backflow?
11.Water cooled ice maker
Is connection present?
Is connection protected with backflow?
12.Medical, dental or dialysis equipment
Is connection present?
Is connection protected with backflow?
13.Laboratory or photo equipment
Is connection present?
Is connection protected with backflow?
14.Mobile or stationary water tank filling
Is connection present?
Is connection protected with backflow?
15.Water system booster pumps
Is connection present?
Is connection protected with backflow?

Please list other processes that are connected to the City of Lincoln water supply:

16.
Is connection protected with backflow?
17.
Is connection protected with backflow?
18.
Is connection protected with backflow?
19.
Is connection protected with backflow?
Leave this field blank: