Cross Connection Control Plan

Union Public Utility District (UPUD)

Cross-Connection Control Hazard Survey

Please complete one survey per service address. Information is used solely for cross-connection control.

Customer Information

Customer Name(s) *

Account Number

Service Address *

Legal Owner (if different)

Phone *

Email (for receipt/updates)

APN #

Assessment Questions

1) Is this property part of a bottled water service? *

Yes No

2) Is the property already protected by a backflow assembly device? *

Yes No

If Yes, provide details (optional)

Type/Model

Serial #

Last Test Date

3) Is there a business on the property? *