City of Fort Calhoun Cross-Connection Survey Nebraska Department of Environment and Energy 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 Fort Calhoun 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 402-306-6242. Your Name:* First Last Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:*Email Address:* Enter Email Confirm Email 1. Do you have a swimming pool or hot tub?**YesNoNot sure1a. If yes, is it filled with a hose bib vacuum breaker or reduced pressure backflow preventer?*YesNoNot sureN/a2. Do you have an underground lawn irrigation system?**YesNoNot sure2a. If yes, is it protected by a testable backflow preventer?*YesNoNot sureN/a3. Do you have lawn or garden chemical sprayers attached to hoses?**YesNoNot sure3a. If yes, is it protected by a hose bib vacuum breaker?*YesNoNot sureN/a4. Do you have a hot water/steam boiler system, not a traditional hot water heater?**YesNoNot sure4a. If yes, is a reduce pressure backflow device installed?*YesNoNot sureN/a5. Do you have a water softener, reverse osmosis system, or other home water system device?**YesNoNot sure5a. If yes, is an air gap or protected backflow device installed and not directly connected to sewer drain?*YesNoNot sureN/aCommentsThis field is for validation purposes and should be left unchanged.
