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Cross-Connection Control Reporting for the City of Minden - RESIDENTIAL

  1. State law requires consumers of public water supplies to inspect their facilities not less that once every five years. Completing & returning this form fulfills that If you requirement! If you have any questions please contact City Hall at (308) 832-1820.

    Completion of this form is a condition of water service! Failure to complete and return this form puts your water system in violation of State Health Department Regulation Title 179.

  2. X X X - X X X X X - X X

  3. Do you have...

  4. 1. An underground lawn irrigation system?*

  5. Is it protected by a testable backflow preventer?

  6. 2. A swimming pool or hot tub?*

  7. Is it protected by a testable backflow preventor?

  8. 3. A photo, chemical, medical, or other lab facilities?*

  9. Is it protected by a testable backflow preventor?

  10. 4. A private well or other source of water?*

  11. Is it protected by a testable backflow preventor?

  12. 5. A boiler heat or water heat pump?*

  13. Is it protected by a testable backflow preventor?

  14. 6. Garden hoses connected to possible contaminants?*

  15. Is it protected by a testable backflow preventor?

  16. 7. A water softener?*

  17. Is it protected by a testable backflow preventor?

  18. Leave This Blank:

  19. This field is not part of the form submission.