Industrial/Commercial Cross-Connection Control Survey

Business Name*

Phone Number*

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

Email*

Provide an email address to receive a copy of your completed form.

Account Number

Service Address*

Street Address

CityState / ProvincePostal / Zip CodeCountry

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

Potentially Hazardous Facilities (select whether the category is applicable to the location served by RSA's water system)*

Rows	YES	NO
Hospitals, Clinics, Veterinary Clinics, Sanitariums, Morgues, and Autopsy Facilities
Boilers/Steam Systems
Chemical Mixing/Injection
Electronics, Plating, Film Processing, and Metal Finishing Facilities
Fire Sprinkler Systems
Medical/Clinical Equipment (Dialysis machines, lab sinks, sterilization units)
Auxilliary Water Systems (wells, reclaimed water, process water)
Water Treatment Systems (Reverse Osmosis, Softener, etc.)
Laundries
Buildings Using Booster Pumps
Wastewater Treatment Facilities
Beverage Bottling and Breweries, Canneries, Packing Houses and Rendering Plants
Plant Nurseries
Oil and Gas Facilities
Clothing, Paper, and Paper Product Manufacturing
Other, please describe:

Other hazards

If there are other potential hazards, please describe here.

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: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

Date

YesNo

Location/Function*

Describe the location or function of the device. For example: "Reverse Osmosis RPZ"

Type of Device*

Manufacturer*

Model*

Serial Number*

Size*

Last Certification Date*

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

Backflow Prevention Device #5

Backflow Prevention Device #6

Section 4: Certification