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Cross-Connection Control Survey: Residential
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Business Information Sheet
Leave This Blank:
The Columbus-Platte County Joint Communications Center would like you to take a few minutes to complete the information below.
This data will assist us in the event that we would need to make contact with a business representative after normal business hours.
Please complete and submit the below form.
A phone call will be made to the business to confirm this information. Thank you for your help.
Business Name
*
Street Address
*
Business Phone Number
*
Business Fax Number
Business Email
After Hours Contact(s)
Primary Contact
*
Phone
*
Alternate Contact
Phone
Alternate Contact
Phone
Hazards on site (hazardous materials, animals on site, etc)
Is your business equipped with an alarm system
*
Yes
No
Alarm Company Name and Phone Number
Please indicate where your entrances/exits are located
*
Hours of operation
*
Special Instructions for Police/Emergency Services
* indicates required fields.
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