edwin22 Please enable JavaScript in your browser to complete this form.Company Name: *Date: *Service Address: *Phone: *Mailing Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompleted By: *Email: * Please Check Your Business Type – Check All That Apply Please Check Your Business Type – Check All That ApplyAutomotiveChurch/ReligiousHospital/Medical FacilityAdministrative OfficeDental FacilityManufacturing PlantApartment/HotelDoctors OfficeMortuary/Funeral HomeBarber/Beauty SalonDistributing PlantRetail Sales & ServiceCar/Truck WashFabricating PlantRestaurantConvenience StoreFood ProcessingSchool/CollegeChemical PlantGas StationWarehouseOther Type of Facility Not Listed: Please Answer the Following Questions Is there a Backflow Preventer (Reduced Pressure Zone Assembly) installed on these buildings domestic water line (NOT IRRIGATION SYSTEM)? *--- Select Choice ---YesNoUnknownIs there more than one water meter supplying this building? *--- Select Choice ---YesNoUnknownPlease select the number of floors of this building (not including basment). *--- Select Choice ---123MoreIf More, How Many? *Do you have water softeners, filters, or treatment systems like deionizers connected? *--- Select Choice ---YesNoAre there any pumps, pressure boosters, or storage tanks connected? *--- Select Choice ---YesNoDoes this property use any steam boilers or chemical feed systems? *--- Select Choice ---YesNoDoes this property have a fire sprinkler system? *--- Select Choice ---YesNoIf yes, what type of system? *--- Select Choice ---Wet PipeDry PipeAntifreezeDoes this property have an underground irrigation system? *--- Select Choice ---YesNoAre decorative fountains, ponds, or pools supplied by the domestic water? *--- Select Choice ---YesNoHow many backflow assemblies are on the property? * If of More, Does Your Facility Contain Any of the Following – Check All That Apply Does Your Facility Contain Any of the Following – Check All That ApplyAC Cooling TowersWater Used in ProcessTesting LaboratoryBoilersCommercial LaundryFilm Processing, including X-rayBooster Pumps (Domestic Water)Swimming PoolChemical Feed LinesPrivate Fire HydrantsWash Basins/SinksToxic or Hazardous MaterialsWash Down HoseGrease TrapsChemical Tanks or VatsGarden Hose SpigotsUnderground Lawn IrrigationEquipment Using WaterChemicals Stored on Site: * Please Select All That Apply to Your Facility Automotive:Automotive: *Paint or Body ShopVehicle RepairSales OfficeCar WashRetail Sales and Service:Do You Prepare and Sell Food on Site? *--- Select Choice ---YesNoDo You Store and Sell Gasoline? *--- Select Choice ---YesNoDo You Sell Antifreeze? YesNoApartments:How Many Units Are Served by This Water Meter? *Church/Religious:Do You Have a Kitchen or Cafeteria? *--- Select Choice ---YesNoDo You Have a Baptistery? *--- Select Choice ---YesNoIf Yes, what is it filled by: *--- Select Choice ---HoseDedicated Fixture Please provide a list of all relevent information, including the materials stored, materials used, and the building tenants. CheckboxesDistributing PlantFood ProcessingManufacturingMulti-Tenant FacilitiesRestaurants or ClubsWarehouse(List Materials Stored)If you have an Air Conditioning Cooling Tower, how is it filled? *--- Select Choice ---Automatic TimerFloat ValveDoes it have an air gap? *--- Select Choice ---YesNoIf so, what is the distance from the outlet piping to the tank rim? *Do you have janitorial mop sinks without built in vacuum breakers in this building? *--- Select Choice ---YesNoDo you have a carbonated fountain drink machine in this building? *--- Select Choice ---YesNoPlease list any equipment tied directly to the domestic water service for this building. *Submit
