EJ Water Cooperative Cross Connection Survey

What is the cross connection survey?

In order to comply with EPA regulations, we are required to conduct a system survey of all members to determine if actual or potential hazards may exist.

Additionally, the results of this survey allows us to ensure that the consumers of our public water supply are protected from the possibility of contamination or pollution arising through an improper cross-connection to the public water supply distribution system. We must have a completed survey concerning water supply usage every two years.

Attention

Failure to respond to this survey may lead to field inspection. Thank you for your time and cooperation.

Personal Information

We want to make sure we have your personal information all up to date.

First Name

Last Name

Account Number

Cell Phone

Receive Text Notifications

Home Phone

Address

City

State

Zip Code

Agricultural

These questions are related to if and how you use your water for agricultural purposes.

Do you raise animals?

Yes No

Water Hydrant

It is important for us to know about your water hydrant.

Is there a water hydrant on your property?

Yes No

Recreational

Tell us about how you use our water for recreational purposes.

Do you have a swimming pool?

Yes No

Do you have a hot tub/spa?

Yes No

Do you fill the pool or hot tub / spa with EJ Water Cooperative water?

Yes No

Terms Of Agreement

I confirm that the information given in this form is true, complete and accurate and agree to the Cross Connection Survey terms of agreement

I Agree to the Terms of Agreement

Cross Connection Survey

Personal Information

Water Service

Agricultural

Water Hydrant

Recreational

Household Utilities

Demographics

Terms Of Agreement