(865) 577-4497

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Commercial Cross-Connect Survey

Please complete the application below to disconnect service.

 

If you have questions regarding disconnecting service, please Email Customer Service or call during normal business hours (865) 577-4497.

 


Date

Account Number

Company Facility

Service Address


Mailing Address


Type of Business

Contact

Phone (999-999-9999)

NUMBER OF SERVICE CONNECTIONS AND TYPE(S) OF EXISTING BACKFLOW PROTECTION:

AIR GAP (AG), REDUCED PRESSURE (RP), DOUBLE CHECK (DC).
PRESSURE VAC (PV), DOUBLE DETECTOR CHECK VALVE (DDCA)

  # SERVICE CONNECTIONS TYPE OF PROTECTION
DOMESTIC:
FIRE:
IRRIGATION:


1. Does facility have an auxillary water supply? yes no
  Is facility interconnected to the public water system? yes no
2. Hazardous materials on premises? yes no
  Water connected? yes no
3. Special uses/equipment requiring water at all times? yes no
4. Heating/cooling systems - water connected? yes no
  a. Air Conditioners yes no
  b. Boilers yes no
  c. Chillers yes no
  d. Cold Storage yes no
  e. Cooling Towers yes no
  f. Heat Exchangers yes no
  g. Refrigeration yes no
  h. Water Cooled Condensers yes no
  i. Water Cooled Equipment yes no
  j. Other:    
5. Industrial Fluids/Pressure Systems - Water Connected: yes no
  a. Booster Pumps yes no
  b. Circulation Pumps yes no
  c. Hydraulic Lines yes no
  d. Hydro-Pneumatic Systems yes no
  e. Priming Lines yes no
  f. Steam Lines yes no
  g. Other:    
6. Chemical Injection/Feeder Systems - Water Connected: yes no
  a. Corrosion/Scale Inhibitors yes no
  b. Algae/Micro-Organism Biocides yes no
  c. Soaps yes no
  d. Softeners yes no
  e. Other    
7. Irrigation Systems: yes no
  a. Chemical/Fertilizer Injection yes no
  b. Booster Pumps yes no
  c. Separate Service Connection yes no
  d. Other:    
8. Laboratory Facilities - With Water Connected Equipment yes no
9. Kitchen Facilities (Commercial) yes no
10. Photo Processing/Printing Equipment - Water Connected yes no
11. Plating Facilities yes no
12. Reclaimed Water/Solvents yes no
13. Swimming Pool/Spa: yes no
  a. Chemical Additives yes no
  b. Low Level Inlet yes no
14. Tanks, Vats, or Other Vessels Containing Non-Potable Substances: yes no
15. Fire Protection Systems - Connected To Public Water: yes no
  a. Unapproved Auxillary Water Supply Available? yes no
  b. Elevated Storage Tanks/Private Reservoirs? yes no
  c. Hazardous Substance(s) in Fire System? yes no
  d. Interconnection With Another Water System Service? yes no
  e. Other:    

Comments:

Required Service Line Protection (AG, RP, DC, DDC, NONE)
Domestic:
Fire:
Irrigation:

Inspector:
Date::


 

 

 

 

 

 

 


 
Knox Chapman Utility District
Mailing Address: P O Box 9569, Knoxville, TN 37940 | Physical Address: 1905 E John Sevier Highway, Knoxville, TN 37920
Office Hours 8:00 a.m.- 4:30 p.m. Monday through Friday
In case of emergency, call (865) 577-4497, ext. 3