Facility and Contact Info | Property Type | Water Sevice Info | Water Use Info | Confirm

Self Assessed Survey

PW-WW-CS-F-013-004 - Rev #6

Answers to fields and questions with an asterisk ( * ) are mandatory

It is an offence under the Backflow Prevention By-law to submit a Self Assessed Survey that contains inaccurate or false information.
Please complete this survey as requested in accordance with the Backflow Prevention By-law #10-103.

Facility Information

Facility or Business Name *

Facility or Business Phone Number *

Format ### ### ####

Facility or Business Address *

Example format: 71 Main St W Hamilton

Facility or Business Postal Code *

Water Meter Serial Number *

Indicate 9 digit serial number located on Alectra bill under "Meter Number" beside "Water"

Property Owner Information

Property Owner Name *

Property Owner Email Address *

Property Owner Phone Number *

Format ### ### ####

Property Owner Address *

Property Owner City *

Property Owner Postal Code *

Contact Person if Different than Owner

Contact Name

Contact Email Address

Contact Phone Number

Person submitting the Survey

Name *

Any personal information on this form is collected under the authority of By-law No. 10-103 and will be used for the protection of the City of Hamilton’s Water Distribution System from reverse flow. Information collected for the Backflow Prevention Bylaw will be stored on servers located in Canada and the United States, and may be subject to Canadian and/or American laws. Questions about the collection of this information should be directed to City of Hamilton, Backflow Prevention Program. 330 Wentworth Street North Hamilton, Ontario L8L 5W2. [email protected]