Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Cross-Connection Questionnaire

  1. Nebraska Department of Health and Human Services Title 179 requires the completion of a Cross-Connection Survey for all water connections to a public water system every 5 years. We ask for your assistance in completing this survey. To meet the state requirements, 100% of City of Papillion water customers must return the survey. If you need assistance in filling out this form, or if you have any questions about cross connections, please call 402-597-2043. Thank you for your cooperation.
  2. Please answer the following questions:
  3. 1. Do you have a lawn sprinkler system?*
  4. 1a. If yes, it is protected by a testable backflow device?
  5. 2. Do you have a swimming pool or hot tub?*
  6. 2a. If you fill it with a hose, does a hose bib vacuum breaker protect it?
  7. 2b. If you fill it with a direct line, is it protected by a reduced pressure backflow preventer?
  8. 3. Do you use a hose aspirator for spraying chemicals? (All hose connections should have a hose bib vacuum breaker.)*
  9. 3a. If yes, is it protected by a hose bib vacuum breaker?
  10. 4. Do you have a fire suppression system?*
  11. 4a. If yes, is it protected by a testable backflow device?
  12. 5. Do you have an ice machine?*
  13. 5a. If yes, is the compressor water-cooled?*
  14. 5b. If yes, is it protected by a testable backflow device?
  15. 6. Do you have a post mix water carbonator?*
  16. 6a. If yes, is it protected by a testable backflow device?
  17. 7. Do you have a water-cooled compressor?*
  18. 7a. If yes, is it protected by a testable backflow device?
  19. 8. Do you have any biological, veterinary, photo, chemical, or medical labs/facilities at this address?*
  20. 8a. If yes, is it protected by a testable backflow device?
  21. 9. Are there any pumps hooked to the plumbing?*
  22. 9a. If yes, please check all that apply:
  23. 10. Are there any other water processes that you may have connected to the water system?*
  24. 10a. If so, what type?
  25. 10c. Are chemicals used in the water?
  26. 10d. If yes, is it protected by a testable backflow device?
  27. Leave This Blank:

  28. This field is not part of the form submission.