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Survey Form
LakeVilla
Backflow Solutions
2020-10-06T13:38:31-05:00
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Residential Survey
Commercial Survey
Lake Villa
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.
Contact Information
Name
*
First
Last
Service Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Account Number
Type of property
*
Residential
Commercial
Water System Information
Please check all that apply to you
Permanent lawn irrigation system
Fire sprinkler system
Boiler
Hot tub/spa directly piped to water supply
Condo Association/HOA
Alternate water source (i.e well, pond, etc.)
Do any existing backflow prevention assemblies exist
Other equipment connections
If other connections, please specify:
Additional Information
Water System Information
Please state your type of business (i.e. restaurant, dry cleaner, etc.)
*
Property Name
Is your mailing address the same as the service address?
*
Yes
No
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Check all the following items at your property
Fire Sprinkler System
Lawn Irrigation System
X-Ray Machine
Large, Commercial Boiler (not a water heater)
Carbonated Beverage Machine
Commercial Ice Maker
Swimming Pool
Cooling Tower
Hose Aspirator for Spraying Chemicals
Medical Equipment
Farm Equipment
Photo Lab
Water Tank Truck Filling Station
Does your business use chemicals, such as a medical facility or a beauty salon?
Yes
No
Do you have any equipment hooked directly to your waterlines?
Yes
No
Additional Information
Are there any backflow assemblies present at your property?
Yes
No
Backflow Assembly
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have an additional device?
Yes
No
2nd Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a 3rd device?
Yes
No
3rd Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a 4th device?
Yes
No
4th Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a multiple additional devices?
Yes
No
Please list the remaining devices you would like to include.
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