Cross-Connection Control Survey

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
Swimming Pool or Hot Tub (Permanently plumbed)
Decorative Pond or Fountain (Connected to water line)
Fire Sprinkler System
Boilers (Hot water heat)
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
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.

YesNoUnsure

Location/Function*

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

Type of Device*

Date of last professional inspection/test

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

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

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

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

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