How to fill out the Residential Cross Connection Survey on the City of McCook's Web Site. 

Nebraska Department of Health & Human Services (Title 179 and McCook Municipal Code (3-127) requires that customers of the municipal water system shall be required to report potential cross connection hazards to the water system once each 5 years.  Each customer must complete this questionnaire and return  it to the city office.  You may drop off the survey at the office, mail it with your next water bill payment, or complete online at www.cityofmccook.com.  Failure to complete and return this form is a violation of municipal code and may result in penalties or interruption of water service

 

Customer Name:*   

The name of the person completing the survey.

Customer Address:*    

 The address of the residential property being surveyed.
Date:*     Current date the survey was completed.
Telephone:     The number where the customer can be contacted..

E-mail:    

A reply E-mail where the customer can be contacted.

                     (* Required Information)

 

Answers 

Yes:   

This potential cross connection exists at this property.

No:   

This type of cross connection does not exist at this property.

Don't Know:   

Water pipes may be concealed.

Place a check mark in the box that best fits your answer per question.

 

CROSS CONNECTION SURVEY

Does your home have any of the following items: Please check one for each question.
Questions Yes No

Don't Know
1.  Underground Lawn irrigation system?
2.  Swimming pool or hot tub?
3.  Photo lab, chemical, medical, or other lab facilities?
4.  Private well or second water service line?
5.  Lawn or garden chemical sprayer attached to hose?
6.  Water softener?
7.  Boiler/Hot water heat?
8.  If you answered yes to any of the questions does your home have a backflow device?
Need help completing the survey call City Offices at 345-2022 ext 222 or Water Shop at 345-3382.

Contact Information

Customer Name*
Service  Address*
Date*
Telephone
E-mail
*Required Information

 

Thank you for completing the Cross Connection Survey.

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