Residential Backflow Survey

Complete the form details below to submit your Backflow Detail survey. This information will be used to help inventory locations that have Cross Connection Control devices throughout your city.

Location Information

Device Types

2730 Highwood Ave E.

Maplewood, MN 55119

phone: (651) 319-9911

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First Name	Last Name
Email Address	Phone Number
Street Address
Street Address 2
City	State	Zip

Location Survey Question	Check if Yes
Do you have a lawn irrigation system?
Do you have a boiler?
Do you have a spa or hot tub connected to the water supply?
Do you have any other alternate water sources on the property such as wells, ponds, etc.?

Manufacturer	Model	Serial #	Size (inches)

Residential Backflow Survey

Survey Questions