Required fields are marked with asterisks (*)

Backflow Prevention Survey Report

This survey must be conducted by a Qualified Person under Town of Aurora Bylaw 6213-19. This form must be submitted by the Property Owner, or Agent, of an Industrial, Commercial, Institutional, or Multi-Residential building. Please complete this form for each service connection at a property.

Section 1:

Facility Name:

Street Number and Name

City/Town

Postal Code

Number of water connections:

Property type

Industrial

Multi-Residential

Commercial

Institutional

Other

Water Account No:

Water Meter Installed:

Yes

Type of Use (e.g. laundry, dental etc.):

Section 2: Owner/Agent

Property Owner First Name

Property Owner Last Name

Mailing Address

City/ Town

Postal Code

Phone

Email Address

Is the Contact Person for the property the same as the Owner?

Yes