Steilacoom, WA · Pierce County
Cross Connection Control Program Questionnaire
This questionnaire helps the Town assess water-system cross-connection hazards; property owners or water customers complete it for premises with listed uses or equipment.
What this form is
The questionnaire identifies premises, fixtures, equipment, or water uses that may create cross-connection hazards and helps the Town assess risks to its water distribution system. Complete the applicable checkboxes and describe each item checked, including how you will comply with applicable cross-connection prevention regulations. The form says manufacturer specifications or additional drawings may be required.
Who needs it
A water customer with a listed premise, fixture, equipment, or water use should complete the questionnaire and describe each applicable item.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
No notary is required; the form asks for a name and date, and states no notarized or sworn attachment or step.
How to submit this form
- 1
Download The Questionnaire
Download the Cross Connection Control Program Questionnaire PDF.
- 2
Complete The Questionnaire
Enter the name, facility address, and date, then check applicable premises, fixtures, equipment, or water uses.
- 3
Describe Checked Items
Describe each checked item and how you will comply with applicable cross-connection prevention regulations.
- 4
Gather Supporting Materials
The form says manufacturer specifications or additional drawings may be required.
- 5
Submit To The Town
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What does the Cross Connection Control Program Questionnaire ask for?
- It asks for the name, facility address, date, applicable premises or water uses, and descriptions of each checked item, including how cross-connection prevention requirements will be met.
- Who should complete this questionnaire?
- A water customer whose premises include a listed category, fixture, equipment, or water use should identify applicable items and describe each one checked.
- Do I need a notary for the Cross Connection Control Program Questionnaire?
- No. The form asks for a name and date and states no notarized or sworn attachment or step.
- How do I submit the Cross Connection Control Program Questionnaire?
- The form does not provide submission instructions. Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Cross Connection Control Program Questionnaire doesn’t need a notary — but if you have another Steilacoom form that does, a commissioned online notary can help.