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

  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. Is there a backflow preventer at this service?*

  5. 2. Do you have a private well for Drinking water, irrigation, or any other purpose?*

  6. 3. OTHER PUMPS: Are there any pumps hooked to your plumbing?*

  7. Check all that apply:

  8. 4. Do you have any of the following? (Check all that apply)

  9. 5. DIRECT CONNECTIONS TO SEWER:*

  10. Leave This Blank:

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