Backflow Device Removal Eligibility Questionnaire.

Does your property have an additional water supply such as a well or canal? (required)

YES

NO

Does your property have a swimming pool or irrigation system supplied by a separate water service or without a satisfactory air gap or anti-siphon device on the inlet line? (required)

YES

NO

Do you have livestock such as goats, cows, horses, donkeys? (required)

YES

NO

Do any of the buildings on your property have an internal booster pump system? (required)

YES

NO

Are any of the buildings on your property three stories or more? (required)

YES

NO

Is there a premises where there are hazardous materials under pressure or where toxic materials are used (hospitals, mortuaries, etc.)? (required)

YES

NO

Does the properties have a fertilizer or chemical injection systems? (required)

YES

NO

Customer Name: (required)

Property Address:

Account Number: (required)

Phone Number: (required)

Email Address: (required)

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