Cross Connections Non-Residential

Cross Connection Inspection Form (Non-Residential)
Fox Crossing Utilities

Facility Information

Facility Type:

Inspection Date:

Inspection Frequency:

Complete?

Yes

No

In Compliance?

Yes

No

Business Name:

Address:

City

State/Province

Zip/Postal

Address:

Main Contact:

First Name

Last Name

Phone:

Location / Size of Service:

Type of Service:

Containment

Potable Supply

# of Inlets

Protection Required

Yes

No

Properly Protected

Yes

No

Type of Protection/ASSE#

Comments

Fire Supply

# of Inlets

Protection Required

Yes

No

Properly Protected

Yes

No

Type of Protection/ASSE#

Comments

Isolation Hazards

1. Lawn Sprinkler(s)

Quantity:

ASSE # or Air Gap:

Properly Protected:

Comments

2. Boilers

Quantity:

ASSE # or Air Gap:

Properly Protected:

Chemicals added?

Yes

No

3. Cooling Tower(s)

Quantity:

ASSE # or Air Gap:

Properly Protected:

Comments

4. Heat Exchanger(s)

Quantity:

ASSE # or Air Gap:

Properly Protected:

Comments

5. Water Cooled A/C

Quantity:

ASSE # or Air Gap:

Properly Protected:

Comments

6. Temporary Machines

Quantity:

ASSE # or Air Gap:

Properly Protected:

Comments

Remarks

Degree of hazard:

Date

Approved

Yes

NoNo

Inspector’s Name

Inspector's Name

First Name

Last Name

Certificate / License #

Inspector’s Signature

Clear

All corrections must be completed and re-inspected. Inspections are done as required by Ordinance 28.47 and Wisconsin Administrative Code NR 811 and Comm 82 by
reference. Please call 920-720-7175 to make an appointment for re-inspection within 30 days of original inspection. Removal of installed items or failure to make required
corrections and to schedule an appointment for re-inspection may result in disconnection of your water service.

Cross Connections Non-Residential

Contact Us