Industrial/Commercial Cross-Connection Control Survey

  • Cross-Connection Control Survey

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

  • Section 1: Customer Information

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

  • This form is meant for commercial, industrial, or agricultural users. Residential users should use the form found here instead: https://form.jotform.com/Rapidan/cross-connection-survey 

  • 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.

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

  • Backflow Prevention Device #1

  • Last Certification Date*
     - -
  • Add another device?

  • Backflow Prevention Device #2

  • Last Certification Date*
     - -
  • Add another device?

  • Backflow Prevention Device #3

  • Last Certification Date*
     - -
  • Add another device?

  • Backflow Prevention Device #4

  • Last Certification Date*
     - -
  • Add another device?

  • Backflow Prevention Device #5

  • Last Certification Date*
     - -
  • Add another device?

  • Backflow Prevention Device #6

  • Last Certification Date*
     - -

  • 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*
     - -
  • Should be Empty: