Nebraska Department of Health, Title 179 Regulations requires that every facility connected to a public water supply, be surveyed for cross-connections once every five years. This regulation requires the “customer” to complete this survey and report the results to their Water Department. In order to assist you, we have developed the following form. Completing and returning this form will fulfill the Nebraska Department of Health’s requirement.
You may mail the completed form to P.O. Box 490, North Platte Nebraska 69103, drop it by at 201 W 3RD ST, E-mail it to HolleyCE@ci.north-platte.ne.us or fax it in to (308)-535-6748
Customer's Name (required)
Site Address (required)
Contact Phone Number (required)
Business Name (if applicable)
If you have any questions please contact your Water Protection Specialist, Christopher Holley, at 308-535-6740 Ext. 6