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City of Brighton 500 South 4th Avenue Brighton, CO 80601 [PHONE REDACTED] Office www.brightonco.gov Residential Cross Connection Plumbing Survey Brighton Utilities Department The safety of Brighton’s water is very important. Residential utility customers are recommended to inspect the plumbing system for potential cross connections to ensure these connections are properly protected against backflow. Please review the brochure regarding plumbing cross connections and complete the simple survey below to assess your risk. Thank you for your interest and assistance in protecting Brighton’s drinking water. Cross Connection Survey Yes No 1. Is there a private well or other source of water supply at this address including wells for geothermal heating/cooling source? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ 2. Is there an underground lawn irrigation system at this address? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ If yes, does the irrigation system have a pump? □ □ If yes, does the irrigation system have a chemical or fertilizer system attached to it? □ □ 3. Is there a swimming pool or hot tub at this address? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ 4. Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical lab at this address? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ 5. Is there a boiler system used to heat the home at this address? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ If yes, are chemicals used in the water? □ □ ---PAGE BREAK--- City of Brighton 500 South 4th Avenue Brighton, CO 80601 [PHONE REDACTED] Office www.brightonco.gov 6. Is there medical, dental or dialysis equipment used at this address? □ □ If yes, is there a backflow preventer in use to protect the public water supply? □ □ 7. Are outdoor spigot anti-siphon missing or defective? □ □ 8. Is there any outdoor hose connected to faucet? □ □ 9. Check swamp cooler connection; is there a direct connection with the water system? □ □ 10. Check water softener connection; is there an air gap on the discharge line? □ □ 11. Check the drinking water filter system, is there an air gap on the discharge line? □ □ 12. Check water lines connected to any appliance: Icemaker □ □ Coffee maker □ □ Humidifier □ □ Other □ □ 13. Check outdoor fountain connections; is there an adequate protection? □ □ 14. Are there other suspected plumbing cross connections at this address? Such as sinks or tubs with hoses, or drain lines to waste pipes or floor drains without air gaps? □ □