City of Hot Springs Form Center

2. Company Name*
3. Date*
   Date

   Date
5. Service Address*
6. Telephone*
8. Account Number*
   See cover letter.
10. Completed by*
12. PLEASE NOTE:
    The return of a survey questionnaire without the company name, date, address, telephone number and account number, or the failure to answer all questions pertaining to your facility, may result in an on-site inspection by the City of Hot Springs.
14. Type of Business*

    Check all that apply.

    1. Automotive Repair/Paint/Sales
    2. Administrative Office
    3. Apartment/Hotel/Condominium
    4. Barber/Beauty/Styling Salon
    5. Bottling Plant
    6. Car/Truck Wash Facility
    7. Convenience Store
    8. Chemical Plant
    9. Church/Religious
    10. Dental Facility
    11. Doctor's Office
    12. Distribution Plant
    13. Fabricating Plant

    1. Food Processing
    2. Gas Station
    3. Hospital or Medical Facility
    4. Manufacturing Plant
    5. Mortuary and/or Funeral Home
    6. Plating Plant
    7. Recycling
    8. Retail Sales & Service
    9. Restaurant
    10. School or College
    11. Warehouse
    12. Other (Please specify type of facility below)
16. Type of Facility Not Listed Above
    Please specify the type of facility not mentioned above.
18. Is there a Backflow Preventer (Reduced Pressure Zone Assembly) installed on this building's water service line?
    Please answer the following questions.
20. Between the water meter and the first outlet (not irrigation system)?
    -- Select One --YesNoUnknown
22. Is there more than one meter supplying this building?
    -- Select One --YesNo
24. Please indicate the number of floors of this building (not including the basement).
    -- Select One --123More than 3 (Please specify below)
26. Number of Floors Not Listed Above
    Please specify the amount of floors not mentioned above.
28. Does Your Facility Contain Any of the Following?

    Check all that apply.

    1. A/C Cooling Towers
    2. Boilers (List Boiler types below.)
    3. Booster Pumps (Domestic Water)
    4. Chemical Feed Lines
    5. Chemical Vats and/or Tanks
    6. Chemicals (List Chemical types below.)
    7. Commercial Laundry (List Commercial Laundry types below.)
    8. Equipment Using Water (List Equipment type below.)
    9. Film Processing Including X-Ray
    10. Garden Hose Spigots (Without Hose Bib Vacuum Breakers)

    1. Grease Traps
    2. Private Fire Hydrants
    3. Swimming Pool
    4. Testing Laboratory
    5. Toxic or Hazardous Materials
    6. Underground Lawn Irrigation (Not on separate meter.)
    7. Wash Basins/Tubs
    8. Wash Down Hose or Mop Sinks
    9. Water Used in Process
    10. Other (List below.)
30. Boiler Types
    Please list the Boiler types mentioned above.
31. Chemical Types
    Please list the Chemical types mentioned above.
33. Commercial Laundry Types
    Please list the Commercial Laundry types mentioned above.
34. Equipment Using Water Types
    Please list the Equipment types mentioned above.
36. Other
    Please list other items not mentioned above.
38. Select Your Type of Facility

    1. Automotive Facilities
    2. Apartments/Condominiums/Mobile Home Parks
    3. Barber/Beauty/Nail Salons
    4. Church/Religious
    5. Paint and Body Shop
    6. Retail Sales and Service
    7. Sales Office
    8. Vehicle Repair
40. How many units are served by this water meter?
41. How many Shampoo Basins do you have?
43. Do you PREPARE and SELL food on site?
    -- Select One --YesNo
45. Do you STORE and SELL gasoline?
    -- Select One --YesNo
47. Do you SELL antifreeze?
    -- Select One --YesNo
49. Do you have a kitchen or cafeteria?
    -- Select One --YesNo
51. Do you have a Baptistery?
    -- Select One --YesNo
52. If you do have a Baptistery, is it filled by a
    -- Select One --hosededicated fixture
54. List all equipment using water at this facility
    Please list all information pertinent to the following, including: materials stored/used and building tenants
56. Facility

    1. Distribution Plant
    2. Food Processing
    3. Manufacturing
    4. Multi-Tenant Facilities
    5. Restaurants or Clubs
    6. School or College
    7. Warehouse (list materials stored)
57. Description
59. If you have an A/C Cooling Tower, how is it filled?
    -- Select One --Automatic TimerFloat Valve
60. Does the Cooling Tower have an air gap?
    -- Select One --YesNo
61. If so, what is the distance from the Outlet Piping to the Tank Rim?
63. Do you have a Freeze Proof or Down Drain type hydrants on this property?
    -- Select One --YesNo
65. Do you have a Carbonated Fountain Drink machine in this building?
    -- Select One --YesNo
66. Please list the type and process at this facility.
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

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