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2021 West Dundee Cross-Connection Control Backflow Survey Form

This survey, mandated by the State of Illinois, will help identify those potable water systems users or customers that require the installation of a Backflow Prevention Device and will prevent the contamination or pollution of the Village water resources.



Please complete the form below to the best of your ability or consult a licensed plumber for assistance.








DO YOU HAVE ANY OF THE FOLLOWING ITEMS AT YOUR PROPERTY?


Fire Sprinkler System Yes No

Cooling Tower Yes No

Lawn Irrigation System Yes No

X-Ray Machine Yes No

Commercial Ice Maker Yes No

Swimming Pool Yes No

Carbonated Beverage Machine Yes No

Farm Equipment Yes No

Water Tank Truck Filling Station Yes No

Medical Equipment Yes No

Industrial/Manufacturing Yes No

Photo Lab Yes No

Hose Aspirator for Spraying Chemicals Yes No














Large, Commercial Boiler (not a water heater) Yes No
Does your business use chemicals, such as a medical facility or beauty salon? Yes No
Do you have any equipment hooked directly to your water lines? Yes No
Are there any backflow assemblies present at your property? Yes No