Commercial/Industria L Service & Backflow Survey.pdf

Account No. Meter No. Size Number of service lines Additional services lines:  Irrigation  Fire protection Reviewed by (print) Signature Date Backflow protection required?  Yes  No Type Please complete this form and return it to our Customer Center at 6125 East Highway 20, Lucerne, CA 95458, or by mail to P.O. Box 1133, Lucerne, CA 95458. If you have any questions, please call us at (707) 274-6624. Thank you. CUSTOMER INFORMATION Customer name Date Service address City Contact name (if different from above) Tax ID Mailing address Phone Alternate phone E-mail address Start Date May we e-mail backflow-related notices?  Yes  No PROPERTY INFORMATION (please check one) What type of property is this?  Commercial  Industrial Is there an irrigation system (sprinklers) on the property?  Yes  No Is there a boiler on the property?  Yes  No Is there a cooling tower on the property?  Yes  No Are there four or more stories in the building?  Yes  No If yes, how many? Is there fire protection (sprinklers) and/or private hydrant(s) on the property?  Yes  No Is there existing backflow protection on the property?  Yes  No Is there a well, non-potable or recycled water, grey or rain water recovery on your property?  Yes  No Do you store hazardous chemicals on-site?  Yes  No If yes, what? Is there equipment that requires the use of water?  Yes  No If yes, please explain. Are there multiple service lines supplying this property?  Yes  No Please describe the type of business activity conducted on this property: I confirm that the information provided above is true and correct, and that I have the authority to respond as the customer of record. Signature Print name RV 2020-06