Commercial Backflow Prevention Survey Form

Backflow systems graphic for reference.

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Backflow systems graphic for reference.

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.

State law requires consumers of public water supplies to inspect their facilities not less than once every five years. Completing & returning this form fulfills that requirement. Completion of this form is a condition of water service. Failure to complete this form puts your water system in violation of State Health Department Regulation Title 179, and may result in a plumbing inspection of the premises.

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

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

Backflow systems reference graphic (pdf)

COMMERCIAL CROSS-CONNECTION CONTROL REPORTING FORM 2026

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