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� ainH tho <br /> SUMP PUMP <br /> e <br /> CROSS CONNECTION <br /> INSPECTION FORM <br /> Name: Date: Time: <br /> Address: 1 st Inspection ❑ Second ❑ <br /> St. Anthony, MN 554 Phone <br /> Own ❑ Rent ❑ Age of Home <br /> A. BASEMENT ❑ yes ❑ no <br /> SUMP BASKET ❑ yes ❑ no <br /> SUMP PUMP ❑ yes ❑ no <br /> MULTIPLE SUMPS ❑ yes ❑ no <br /> • Was water in the basin during inspection? ❑ yes ❑ no <br /> Discharge Point: ❑ Laundry Tub ❑ Sanitary Sewer ❑ Outside <br /> ❑ Floor Drain ❑ Other? <br /> When was system installed, or most recently modified? (date) <br /> Why? ❑ home came with system ❑ response to inspection program <br /> ❑ water in basement or ❑ other <br /> previous system failed <br /> B. ROOF LEADERS ❑ yes ❑ no <br /> Discharge: ❑ Near foundation ❑ Away from foundation <br /> ❑ Other <br /> PASS: ❑ FAIL: ❑ REINSPECT <br /> Inspector: Date: <br /> • Date: Time: <br /> Resident: To make an appointment for <br /> Date: reinspection call <br />