Celina, OH · Mercer County
Cross Connection/Backflow Survey Sheet
Celina Utilities uses this sheet to record customer and property details and survey conditions related to cross connections and backflow.
What this form is
This field survey sheet records customer contact details, water line and backflow device information, and possible cross-connection conditions at a property. It asks about auxiliary water supplies, pumps, boilers, fire protection systems, and other equipment, along with whether follow-up is required. The sheet identifies the surveyor and survey date but does not state when the city requires the survey.
Who needs it
A customer or surveyor involved in a Celina cross-connection or backflow survey can use this sheet to document property conditions and follow-up needs.
How to submit it
Send it to Celina Utilities at 7148 Sugar Street, Celina, Ohio 45822, or use the phone, fax, or email listed on the sheet.
About notarization
This sheet has no notary block; the surveyor records their name and date, and no sworn attachment or notarized step is listed.
How to submit this form
- 1
Download The Survey Sheet
Download the Cross Connection/Backflow Survey Sheet PDF.
- 2
Complete The Survey Details
Record the customer, property, backflow device, and applicable equipment and water supply details.
- 3
Record Survey And Follow-Up
Enter the surveyor and date, and indicate whether follow-up is required and why.
- 4
Send It To Celina Utilities
Send the sheet to the Utilities address, fax, or email listed on the document.
Frequently asked questions
- What does the Cross Connection/Backflow Survey Sheet record?
- It records customer and property information, backflow device details, possible cross-connection conditions, and whether follow-up is required.
- Who uses this survey sheet?
- A customer or surveyor involved in a Celina cross-connection or backflow survey can use it to document property conditions and equipment.
- How do I submit the Cross Connection/Backflow Survey Sheet?
- Send the completed sheet to Celina Utilities at 7148 Sugar Street, Celina, Ohio 45822, or use the phone, fax, or email listed on the sheet.
- Do I need a notary for the Cross Connection/Backflow Survey Sheet?
- No. The sheet has no notary block; the surveyor records their name and date, and no sworn attachment or notarized step is listed.
Need something notarized?
This Cross Connection/Backflow Survey Sheet doesn’t need a notary — but if you have another Celina form that does, a commissioned online notary can help.