Residential or Commercial?*What is the type of property for which you are completing this questionnaire? Residential CommercialCustomer Account Number (Optional):Email Address* Name* First Last Business Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Plumbing or Activity Present on Premises (Residential)Please indicate whether the special plumbing or activities below apply to your premises:Underground irrigation sprinkler system* Yes NoWater treatment system (e.g, water softener)* Yes NoSolar heating system* Yes NoResidential fire sprinkler system* Yes NoOther water supply*(whether or not connected to plumbing system, e.g. well) Yes NoPortable dialysis machine or equipment* Yes NoBoat dock/moorage with water supply* Yes NoHobby farm* Yes NoLivestock or Animal watering troughs* Yes NoSwimming pool or hot tub* Yes NoGreenhouse* Yes NoDecorative pond* Yes NoPhoto lab or dark room* Yes NoHome-based business.*If Yes, list type or describe (e.g., beauty salon, machine shop, etc.): Yes NoDescription of Home-Based Business*Please list the type or describe your home-based business (e.g., beauty salon, machine shop, etc.):Non- Residential Water Use Questionnaire (Commercial)Business / Premises Type*Is your business or premises of a type included in the table below (check all that apply)? Select All Agriculture( farm or dairy) Beverage bottling plant Car wash Chemical plant Commercial laundry or dry-cleaners Having both reclaimed water and potable water provided Film Processing plant Food Processing plant Hospital, medical center, nursing home, veterinary, medical or dental clinic, or blood plasma center Having separate irrigation system using purveyor’s water and adding chemicals* Laboratory Fire Sprinkler System Metal Plating industry Mortuary Petroleum processing or storage plant Pier or dock Radioactive material processing plant or nuclear reactor Wastewater lift station or pumping station Survey access denied or restricted Wastewater treatment plant Having an unapproved auxiliary water supply interconnected with the potable water supply Irrigation System Swimming Pool OtherOther, please explain:*This form is used for preliminary assessment only. The water purveyor may require a more thorough assessment at a later date.SignatureCompleted by*Please type your name to serve as a digital signature.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
