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 submitting this form will fulfill the Nebraska Department of Health’s requirement.
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