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2. CROSS CONNECTION (BACKFLOW PREVENTION) SURVEY

   The Illinois Environmental Protection Agency (IEPA) requires every water supplier to develop and implement a cross-connection (backflow prevention) control program. One program requirement is to survey all residential water customers in the Village's service area every two years. All residential water customers are asked to complete the survey. For questions regarding the program or survey, contact the Water & Sewer Superintendent Tom Kopanski at 331-212-9042 or tkopanski@montgomeryil.org.

   The Village of Montgomery Public Works Department - Water & Sewer Division provides quality and safe drinking water to all Montgomery residential and commercial users. The Village of Montgomery adopted a Cross Connection Control Program to ensure safe drinking water.

4. FIRST NAME
5. LAST NAME
7. ADDRESS*

   Please list the full street address, including the apartment or unit number, if applicable.

9. Email*

   Please provide an email address for one person residing at the residence for which you are completing the survey.

10. Are you interested in receiving the Village e-newsletter?
    -- Select One --YesNo
12. Is this address Residential or Commercial?*

    1. Residential
    2. Commercial
14. Do you have an underground lawn sprinkler system?*

    1. Yes
    2. No
16. Do you have a swimming pool or hot tub?*

    1. Yes
    2. No
18. Do you have a water treatment system other than a water softener?*

    1. Yes
    2. No
20. If yes, what additional treatments are you doing?
22. Do you pull water from a source other than from the Village of Montgomery?*

    1. Yes
    2. No
24. Do you have a boiler or steam heat?*

    1. Yes
    2. No
26. Do you have a biological or chemical lab onsite?*

    1. Yes
    2. No
    3. Does not apply
28. Do you have dental or dialysis equipment onsite?*

    1. Yes
    2. No
    3. Does not apply
30. Any additional information or comments you would like to share regarding your water service connection?
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field