Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Cross Connection Control Survey

  1. The Illinois Environmental Protection Agency (IEPA) requires that all water systems in the State of Illinois have an effective Cross Connection Control Program. Cross connections are a serious concern as they can allow contaminants to enter the public water system through “backflow”. Backflow occurs when a drop in water pressure causes water to flow in the opposite direction. This can allow contaminated water to flow back into your drinking water. Given IEPA regulations and the dangers that exist from unprotected cross connections, an effective cross connection control program is necessary to protect our customers as well as the integrity of the Village of Roselle’s water supply. One necessary component of our program is a survey to determine where cross connections may exist. We are requesting that you complete the survey below. By working together and completing the survey, we can further protect our water from potential contamination. If you have any questions regarding this survey, please contact the water division at (630) 671-2368. Thank you for your assistance.

  2. Roselle, IL 60172

  3. Indicate which of the following are present at the address indicated above.*

    Please check all that apply.

  4. Leave This Blank:

  5. This field is not part of the form submission.