The information you provide is for the evaluation of potential cross-connections and backflow requirements for the protection of the City's water supply. When completing this form it is required that you submit your name, address and either phone number or email address. Anonymous submissions cannot be accepted.

Demographic Questions

Your name*

Physical Address of the property*

Property Type:*

Residential Commercial Industrial School Preschool or Daycare Restaurant Residence w/Home-based business Church/Worship Facility

Tell us the name of the business. (enter n/a if not applicable)*

Do you own the property or rent?*

Own Rent or Lease

Name of Property Owner if other than you

Address of Property Owner if other than you

The meter at this location serves*

Single Family Home Twinplex/Duplex Apartments Business or Commercial Property Multi-unit Business or Plaza Home-based Business

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

Waterfront Property Jacuzzi /Hot Tub/Spa Greenhouse Fire Sprinkler System Lawn Sprinkler System Photo Processing Lab / Equipment

Processing Fluids or Chemicals Boiler Water/Heater System Swimming Pool Utility Sink with threaded faucet Dental Processing Equipment None of the above

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

Antifreeze Flush Kits Darkroom Equipment Insecticide Sprayer (that attaches to a garden hose)

Dialysis Equipment Lab Equipment/Chemicals None of the above

Do you have a bathtub that fills from the bottom, or does not have an overflow drain and is not air gapped?*

Yes No

Do you have a water softener or any other treatment system?*

Yes No

If yes, which do you have?

Water Softener Reverse Osmosis

Ionic System Other

Do you have an auxiliary water supply or well?*

Yes No

Does a creek, lake, river or spring run near your property?*

Yes No

If yes, do you ever pump or draw water from this source?*

Yes No

Do you have a booster pump, well pump, or any other type of water pump?

Yes No

If yes, describe:

If you receive irrigation water from another source, please describe: *

Do you have a backflow prevention device on your property now?*

Yes No

Do you have any other water using equipment on your property not mentioned above?*

Comments Section

Comments

Contact Information

Name*

Telephone Number:*

Email Address:

If you have any questions or concerns, please contact Munroe Falls Water Department at 330-688-7491 ext 223 or email water@munroefalls.com