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July 13, 2014 - 03:19AM
Residential Survey - Water Cross Connections

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Thank you for taking the time to complete our Water Cross Connections Survey. Please complete as much of the form as possible selecting as many or as few items as applicable. For verification purposes please enter your address, this helps to prevent duplicates.

Please contact the Water Treatment Plant at 793-6536 with any questions.

* Address:
Date:

Hot Tub: Yes
No
Vacuum Breaker
Hard (Direct) Piped

Pool: Yes
No
Vacuum Breaker
Hard (Direct) Piped

Irrigation: Yes
No
 

Backflow Device: Yes
No
 

Other:
Steps Taken:

Inspector:
Date:

Items with an * are required.

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The City of La Vergne does not discriminate based on race, color or national origin in federal or state sponsored programs, pursuant to Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d). If you receive a Title VI complaint, please contact the Title VI coordinator Fred Gaston at 287-8622.
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