ENVIRONMENTAL GRANT APPLICATION - American Water …
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| |
|Customer Cross Connection |
|and Backflow Protection Survey |
|Name: |
|Company/Organization: |
|Address of Premise Survey Relates to: |
|City: |State: |Zip Code: |
|Phone: |E-mail: |
|Meter No. (Provided on your water bill): |Premise No. (Provided on your water bill): |
|Does this meter service multiple units? Yes ( No ( Type of units: Duplex ( Apartment ( Business ( Mixed Use ( |
|GENERAL WATER USE at your location (other than fire protection) |
| | |
|Please check ALL boxes that apply/best describe the use of water at your |Please check ALL types of backflow prevention devices installed on your |
|facility. |plumbing system. |
| | |
|( Typical, such as bathrooms, drinking fountains, outside water |( None |
|faucets, household laundry or dishwashing appliances. |( Residential Dual Check (RDC) |
|( Private well(s) supplying any part of your facility. |( Reduced Pressure Zone Device (RP) |
|( Piped into a manufacturing process. |( Double Check Valve (DC) |
|( Piped into a chemical process. |( Pressure Vacuum Breaker (PVB) |
|( Piped, underground lawn sprinkler/irrigation system. |( Other ______________________________ |
|( Piped into a swimming pool. | |
|( Piped into water operated/cooled equipment/appliances/boilers. |Existing Device Information (if applicable): |
|( Medical, pathology, research chemical or bacteriological lab. | |
|( Piped into photo processing lab. |Manufacturer__________________ Model____________________ Serial |
| |#____________________ |
| |Size_________ Type: (Circle) RP : DC : PVB : RDC |
|FIRE PROTECTION SERVICES |
| | |
|Please check ALL boxes that apply/best describe your fire protection |Please check ALL types of backflow prevention devices installed on your |
|account: |sprinkler system. |
| | |
|( This account serves private hydrants only (no fire sprinkler |( None |
|system in facility). |( Reduced Pressure Zone Device (RP) |
|( This account serves an installed fire sprinkler system. |( Reduced Pressure Principle Detector Assembly (RPDA) |
|( Fire sprinkler system has outside fire department connections |( Double Check Valve (DC) |
|for pumping into system. |( Double Check Detector Assembly (DCDA) |
|( Fire sprinkler system contains antifreeze or other chemicals. |( Other ______________________________ |
|( Fire sprinkler system is also supplied by an auxiliary source of | |
|water (i.e., pond, reservoir or storage tank). |Existing Device Information (if applicable): |
| | |
| |Manufacturer__________________ Model____________________ Serial |
| |#_____________________ |
| |Size_________ Type: (Circle) RP : DC : DCDA : RPDA |
|If backflow prevention devices are installed on your plumbing/fire sprinkler system, it is required by the Pennsylvania Department of Environmental|
|Protection that they be tested annually and copies of the test reports be maintained on file with the water company. If you do not have current |
|copies of the test reports on file with us, please attach to this survey. Test report form can be found on our website at |
|. Select Ensuring Water Quality. |
|Signature |
|Signature of person completing this survey: |Date: |
| | |
Please return completed form for Virginia American Water or Maryland American Water by mail, email or fax to:
By Mail: 2223 Duke Street, Alexandria, VA 22314 Attn. Cross Connection Department.
Fax: 703-836-6652
Email at va.c@
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