Cross-Connection Control Survey

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.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

Fill this field to receive a copy of your submission.

Account Number

Service Address*

Street Address

CityState / ProvincePostal / Zip CodeCountry

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

Potential Hazards*

Rows	YES	NO
Underground Irrigation/Sprinkler System (connected to RSA water system)
Swimming Pool or Hot Tub (Permanently plumbed)
Decorative Pond or Fountain (Connected to water line)
Fire Sprinkler System
Boilers (Hot water for air heating. This is not referring to water heaters)
Water Softener or Treatment System
Auxiliary Water Source (Well, Cistern, Spring, Creek)
Livestock Watering Troughs or Yard Hydrants
Solar Water Heating System
Photo Lab, Medical Equipment, or Chemical Tanks
Any pumps used to increase water pressure
Utility Sink (when a hose is attached to the faucet, there is a risk of siphoning)
Insecticide Sprayers (attached to garden hose)
Other, please describe:

Other hazards

Describe any other hazards that may exist at your service location.

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.

YesNoUnsure

Location/Function*

Describe the location or function of the device. For example: "irrigation system"

Type of Device*

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)

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "irrigation system"

Type of Device*

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)

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "irrigation system"

Type of Device*

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)

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "irrigation system"

Type of Device*

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)

Date

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.

Signature*

Date*

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.

Cross-Connection Control Survey

Section 1: Customer Information

Section 2: Potential Hazards Checklist

Section 3: Backflow Prevention Device Status

Backflow Prevention Device #1

Backflow Prevention Device #2

Backflow Prevention Device #3

Backflow Prevention Device #4

Section 4: Certification