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2. Business Name*
4. Address1*
6. Address2
8. City*
9. State*
10. Zip*
12. Phone Number*
13. E-mail Address*
15. Business Type*
17. Are you the property owner?

    1. Yes

    1. No
19. Owner Name
21. Owner Address1
23. Address2
25. City
26. State
27. Zip
29. Owner Phone Number
30. Owner E-mail Address
32. Number of units on property*
34. Please indicate which of the following you have:
36. Alternate Water Source*

    1. Yes

    1. No
37. If yes, please indicate which source you have

    1. Well
    2. Cistern
    3. Reclaimed Water (Excluding Rain Barrels)
39. Baptismal Fountain/Tub*

    1. Yes

    1. No
41. Boiler or Steam Heat*

    1. Yes

    1. No
42. If yes, please indicate boiler type

    1. 200,000 or < BTU/hour
    2. +200,000 BTU/hour
    3. Not Sure
44. Car Wash Facilities*

    1. Yes

    1. No
46. Chemical Feeder*

    1. Yes

    1. No
48. Chlorinator*

    1. Yes

    1. No
50. Commercial Dishwasher*

    1. Yes

    1. No
52. Dental Equipment*

    1. Yes

    1. No
54. Fire Sprinkler Protection System*

    1. Yes

    1. No
56. Industrial Fluid System*

    1. Yes

    1. No
58. Lawn Irrigation System*

    1. Yes

    1. No
60. Private Yard Hydrant*

    1. Yes

    1. No
62. Photo Processor*

    1. Yes

    1. No
64. Pressure Booster*

    1. Yes

    1. No
66. Shampoo Bowl/Sink*

    1. Yes

    1. No
68. Soap Injector*

    1. Yes

    1. No
70. Soft Drink Dispenser*

    1. Yes

    1. No
72. Steam Equipment*

    1. Yes

    1. No
74. Sterilizer*

    1. Yes

    1. No
76. Swimming Pool/Hot Tub*

    1. Yes

    1. No
78. If yes, how do you fill your pool/hot tub?
80. Truck or Tank Filling*

    1. Yes

    1. No
82. Water Cooled Equipment*

    1. Yes

    1. No
84. Other Equipment with a Direct Connection to City Water*

    1. Yes

    1. No
86. If yes, please indicate what equipment connects to City Water.
88. Do you have backflow preventers on your property?*

    Backflow Preventer

    1. Yes

    1. No

    1. Not Sure
90. Pictures of devices in question can be e-mailed for review by the City’s Plumbing Inspector. The City’s Plumbing Inspector can also be contacted via phone at 309.524.2374.
92. Installation Date
93. Serial Number
95. Size
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97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field