Cross-Connection Control Survey

  • Cross-Connection Control Survey

    Help us ensure your water system's safety and compliance.

  • If you have questions while completing this form, visit www.rapidan.org/cross-connection-control for more information about backflow protection. You may also contact us at (540) 972-2133.

  • Section 1: Customer Information

  • Format: (000) 000-0000.
  • Property Type*

  • This form is meant for residential customers. Industrial, Commercial, or Agricultural customers should complete this survey: https://form.jotform.com/Rapidan/industrial-commercial-backflow

  • Section 2: Potential Hazards Checklist

  • Rows

  • Section 3: Backflow Prevention Device Status

  • The items listed in the previous section are just a subset of many potential cross connection hazards that can cause serious injury to users of your community water system. Anywhere potable water comes into contact with a non-potable substance is a contamination risk that must be mitigated by proper Backflow Prevention Devices.

    Visit www.rapidan.org/cross-connection-control for more information about backflow protection.

  • If you answered YES to any hazards above, do you have a backflow prevention device installed?

  • Backflow Prevention Device #1

  • Date of last professional inspection/test, if known. (Atmoshpheric Vacuum Breakers like you would use on a hose bibb do not require professional inspection or testing)
     - -
  • Add another device?

  • Backflow Prevention Device #2

  • Date of last professional inspection/test, if known. (Atmoshpheric Vacuum Breakers like you would use on a hose bibb do not require professional inspection or testing)
     - -
  • Add another device?

  • Backflow Prevention Device #3

  • Date of last professional inspection/test, if known. (Atmoshpheric Vacuum Breakers like you would use on a hose bibb do not require professional inspection or testing)
     - -
  • Add another device?

  • Backflow Prevention Device #4

  • Date of last professional inspection/test, if known. (Atmoshpheric Vacuum Breakers like you would use on a hose bibb do not require professional inspection or testing)
     - -

  • Section 4: Certification

  • I certify that the information provided above is true and accurate to the best of my knowledge. I understand that RSA reserves the right to inspect my plumbing system to ensure compliance with Virginia Department of Health (VDH) regulations.
  • Date*
     - -

  • We welcome your feedback on this form. Please contact us at (540) 972-2133 with questions or feedback.

    Additionally, visit www.rapidan.org/cross-connection-control to see more information about cross-connection control and backflow protection.

  • Due to the high volume of submissions, there may be a delay after clicking "Submit Survey."  We appreciate your patience and participation. 

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