Customer Cross Connection and Backflow Assembly Survey
Step 1: Premise Information
Hazard ID:
Premise ID/Account Num:
Meter Number:
Name:
Company/Organization:
Site Address:
Site City:
Site State:
Select...
Illinois
Indiana
New Jersey
North Carolina
Ohio
Pennsylvania
Texas
Virginia
Site Zip Code:
Phone:
Email:
Is the Property:
Residential Only
Commercial, Industrial or Mixed Use
Please Identify any Existing Backflow Protection at the Premise
Device 1(if installed):
Manufacturer
Size
Model
Serial
Double Check Valve(DC)
Reduced Pressure Zone Device(RPZ)
Atmospheric Vacuum Breaker(AVB)
Spill-Resistant Vacuum Breaker(SVB)
Pressure Vacuum Breaker(SVB)
Air Gap(AG)
Double Check Detector Assembly(DCDA)
Reduced Pressure Principle Detector Assembly(RPDA)
Residential Dual Check Valve(RDC)
Unknown
Type
Containment
Isolation
Unknown
Protection
Device 2(if installed):
Manufacturer
Size
Model
Serial
Double Check Valve(DC)
Reduced Pressure Zone Device
Atmospheric Vacuum Breaker(AVB)
Spill-Resistant Vacuum Breaker(SVB)
Pressure Vacuum Breaker(SVB)
Air Gap(AG)
Double Check Detector Assembly(DCDA)
Reduced Pressure Principle Detector Assembly(RPDA)
Residential Dual Check Valve(RDC)
Unknown
Type
Containment
Isolation
Unknown
Protection
