Commercial/Industria L Service Application And 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 201 South First Street, Dixon, CA 95620. If you have any questions, please call us at (707) 678-5928. 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 (sealed vessel where water is converted to steam; does NOT refer to water heaters) Is there a cooling tower on the property? Yes No (cooling system used for industrial purposes to cool hot water; does NOT refer to air-conditioning unit) 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 DIX 2020-06