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City of Crete Nebraska


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Commercial Backflow Prevention Survey Form

Sample: Backflow form mailed to commercial utility customers.

A cross-connection reporting form is mailed to all commercial utility customers and can be returned by mail in the envelope provided or it can be filled out and submitted below to fulfill the reporting requirement. All fields are required. If you wish to continue to receive water service within the City you must return the completed form to the Office if the Building Inspector, as it is a State requirement.

Please make sure you have included your address in the appropriate spaces.

If you have any questions please contact Brad Bailey, City of Crete Building Inspector, at 402.826.4312.


Please inspect your plumbing system and select an answer to the following questions. 



Is there any , such as a private well, pond, tank, cistern, or reclaimed water? 

Is there a  on the main service? 

If so, has it been 

If yes, provide  and date: 

If there is a , what is the make, model, serial number, type, and date installed. (If there is no device in place, type "no device.")

If a backflow device is installed, where is the ? (Please be specific.) 

The information provided in this survey form is an accurate and current description of the water system at this address.

Name of