This bi-annual survey form must be completed and sent to the Village of Palos Park Water Department. Please send the
survey to VILLAGE OF PALOS PARK WATER DEPARTMENT 8999 West 123rd Street Palos Park, Illinois 60464 or e-mail to
firstname.lastname@example.org. Data from this form may be used to determine if the property should be inspected by a licensed plumber with
a CCCDI certification to detect and correct any cross-connections found on the property.