A “cross connection” is an unprotected actual or potential piping or plumbing arrangement between a customer's piping system and the public water system through which a substance other than potable water could flow back into the public system.
In 2010 the Cross Connection Control & Backflow prevention program was approved by the Virginia Department of Health Office of Drinking Water and adopted by the City of Norton. Under the program the City of Norton is required by the Virginia Department of Health Office of Drinking water to to ensure the proper backflow prevention device(s) are in place to protect the water supply of contamination. Our first step in implementing the Cross Connection Control Program is to survey our customers. Your cooperation is needed in order to reduce the chance of contaminating our water system. You are asked to complete and return the survey form within 30 days.
If further information is needed please contact: Andrew Greear by phone: 679-1205, by email: andrewg@nortonva.gov or Winfred Collins by phone: 679-1160.

Company Name:*

Street Address:*

Email:

Telephone:*

Please check any item category that may apply to your premises:

Hospital, Mortuary, Clinic, Veterinary, Nursing Home, Dental, Medical Building Laboratory Sewage Treatment, Sewage Pumping, or Storm Water Pumping Food/Beverage Processing Plant Chemical Plants, Dyeing Plants and Pharmaceutical Plants Metal Plating Industries Petroleum or Natural Gas Processing or Storage Plants Radioactive Materials Processing Plants or Nuclear Reactors Car Washes and Laundries Water Loading Station Lawn Care Companies and Their Vehicles with Storage or Mixing Tanks Slaughter Houses, Poultry Processing Plants and Other Food Processing Operations

Farms Where the Water is Used for Other than Household Purposes Commercial Greenhouses and Nurseries Health Clubs with Swimming Pools, Therapeutic Baths, Hot Tubs, or Saunas Paper and Paper Products Plants and Printing Plants Pesticide or Extermination Companies and Their Vehicles with Storage/Mixing Tanks Schools or Colleges with Laboratory Facilities High-Rise Buildings (4 or more stories) Multi-Use Commercial, Office, or Warehouse Facilities High Density, Multi-Use Residential Complexes Served through a Master Meter Fire Protection Sprinkler System Lawn Irrigation System

Please check any backflow prevention devise(s) that may apply to your premises:

Air Gap RP or RPZ Pressure Vacuum Breaker Double Gate – Double Check Valve

Check Valve Vacuum Breaker None

Total Number of Backflow Devises:

Date of Last Inspection or Testing:*

Inspector/Tester Name:

Inspector/Tester License Number: