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

Water & Sewer

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
Water Bill Sample
Format ### ### ####
Example format: 71 Main St W Hamilton
Indicate 9 digit serial number located on Alectra bill under "Meter Number" beside "Water"
Property Owner Information
Format ### ### ####
Contact Person if Different than Owner
Person submitting the Survey

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. backflow@hamilton.ca