Is this a residential or commercial property? (required)ResidentialCommercial

If commercial, please specify business name (if more than one business is serviced by one service connection; ie multi-unit commercial, please see Attachment 1 at the bottom of this form)

Are you renting or do you own this property? (required)RentOwn

If renting, please provide name and address of owner:

Your water meter serves how many homes (Residential Properties)? (required)

How many buildings? (Commercial Properties: If more than one, please see Attachment 1) (required)

Do you have any of the following? (check all that apply) (required)

Swamp cooler connected to piping

Hot tub (fills with a hose or automatic filler)

Swimming Pool

Underground sprinkler system

Drip irrigation system

Greenhouse

Onsite water storage

Cooling (Chillers)

Solar System

Water makeup lines (boiler, hydronic heating)

Utility sink with threaded faucet (hose attachment)

Fire sprinkler system

Unknown, unidentifiable or complicated piping

None

Do you use any of the following? (Check all that apply) (required)

Antifreeze flush kits with your automobile

Insecticide sprayers (that attach to a garden hose)

Darkroom or photo developing equipment

Fill adapters for waterbed, fish tank or other

None

Does anyone on the premises use a portable dialysis machine? (required)YesNo

Do you have a bathtub or hot tub that fills from the bottom or does not have an overflow drain or the fill spout is not above the tub rim? (required)YesNo

Do you have a water softener or any other water treatment system connected to your drinking water supply? (required)YesNo

Do you have auxiliary water supply (i.e. well, pond) on your premises? (required)YesNo

Do you have livestock (i.e. horses, cows, etc.) that use a water trough? (required)YesNo

Is the water piping that enters your home more than 10 feet above your water meter? (required)YesNo

Does a creek, river, or spring run near your property? (required)YesNo

If you answered "Yes" above, do you pump or draw water from this source?YesNoNA

Do you have a booster pump, well pump, or any other type of water pump? (required)YesNo

Do you receive irrigation water from a different source? (required)YesNo

Do you have any other water using equipment on your property not mentioned above? (required)YesNo

If yes, please describe

Is water used for any of the following on your property? (required)

Food preparation

Manufacturing

Processing

Industrial

None

Do you have any backflow prevention device(s) and/or assembly(s) on any equipment at your site? (required)YesNoUnknown

If yes, please provide: Manufacturer, Serial Number, and Model Number

Type of device(s) and/or assembly(s): (required)Reduced Pressure PrincipleAtmospheric Vacuum BreakerPressure Vacuum BreakerDouble CheckNone

Comments:

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Please notify ELCO if any of the above conditions change on your property such as remodeling, changes or additions to your water piping system.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Phone Number (required)

Best time to call or alternate contact (required)

Email Address

Today's Date (required)

Mailing Address (required)

Site Address (if different) (required)

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Please answer all of the above questions and return the questionnaire within 30 days. This form will be kept on file at ELCO. If you have any questions please call us at 970-493-2044 ext. 316.

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Please return survey report form to: Alex Ainsworth, ELCO, 232 S Link Ln Fort Collins, CO 80524

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Per District policy, failure to comply with backflow questionnaires and/or on site surveys, can result in termination of water services.

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Thank you, your submission has been received.

If Attachment 1 was neccesary for you to fill out, please email it to alexandera@elcowater.org. 

If you are having issues with the online form, please ensure you are answering all required questions.

If you are still having issues, or would like a paper copy, please download a copy of the Cross Connection Survey below to drop by our office at 232 S Link Ln Fort Collins, CO 80524, mail to PO BOX 2044 FORT COLLINS, CO 80522, or scan and email to alexandera@elcowater.org.