2023 Resident Reporting

All Wilber Resident’s should have received the Cross-Connection Control Report and Lead Service Line Questionnaire with their February utility bill. We are required to collect this information from all of our residents so we need your help to get them back. We are offering multiple ways to submit your form, if you have not already.

Complete the online form(s) below.
Click on the form name below to get a printable copy of the form and for instruction on how to check your lead service.

The printed form can be dropped off at the City Office located at 110 W 3rd Street or…

Upload your completed paper form here.

Cross-Connection Control Reporting Form

State law requires consumers of public water supplies to inspect their facilities not less than once every five years. Completing and returning this form fulfills that requirement! COMPLETION OF THIS FORM IS A CONDITION OF WATER SERVICE! RESIDENTIAL SURVEY FORM FOR THE WATER SYSTEM OF THE CITY OF WILBER

Customer Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Number(Required)

Underground lawn irrigation system?(Required)

Is it protected by a testable backflow preventer?

Swimming Pool or Hot Tub?(Required)

Is it protected by a testable backflow preventer?

Photo, chemical, medical, or other laboratory facilities?(Required)

Is it protected by a testable backflow preventer?

Private well or other source of water?(Required)

Is it protected by a testable backflow preventer?

Boiler heat or water to air heat pump?(Required)

Is it protected by a testable backflow preventer?

Are garden hoses connected to any possible contaminants?(Required)

Is it protected by a hose bibb vacuum breaker?

Do you have a water softener?(Required)

Is it protected by an air gap?

Consent

By checking this box and printing your name below, you are verifying that all of the information listed above is accurate to the best of your knowledge.

Print Name

Date

Lead Service Line Questionnaire - English

Do you have a lead service line? Answer a few questions to protect your family's health and help your utility identify the drinking water service line materials in your community.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year Home was built:(Required)

Account Number(Required)

Is the original Service Line material still present?(Required)

Service Line Material(Required)

Are there other Lead Materials present?(Required)

Other

Lead Service Line Questionnaire - Español

¿Tiene una línea de servicio de plomo? Responda algunas preguntas para proteger la salud de su familia y ayudar a su empresa de servicios públicos a identificar los materiales de la línea de servicio de agua potable en su comunidad.

Nombre(Required)

First Last

Dirección(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Año en que se construyó la casa:(Required)

Número de cuenta(Required)

¿El material original de la línea de servicio todavía está presente?(Required)

Material de la línea de servicio(Required)

¿Hay otros materiales de plomo presentes?(Required)

Otros