A cross-connection survey form is a questionnaire your water utility sends to document every point on your property where drinking water could come into contact with a non-potable source. You complete it by walking your property, checking the plumbing features and water-using equipment that apply, recording the details of any backflow prevention device already installed, attaching a current test report if you have one, signing, and returning it by the deadline printed on the form. Most utilities give you 30 days or less.
Why Your Utility Sent It
Water suppliers are responsible for delivering water that meets federal quality standards all the way to your meter, and that includes preventing contaminants on customer properties from flowing backward into the distribution system.1Environmental Protection Agency. Cross-Connection Control Manual Cross-connection control programs are run at the local utility level through municipal ordinances, which is why the form comes from your provider and why the specific questions, deadlines, and penalties differ from one system to the next.
What the Form Asks
Most surveys open with your account information (name, service address, account number) and then move into a checklist of features on the property. You check every item that applies and leave the rest blank. A typical residential survey covers:
- In-ground sprinklers, drip lines, or any irrigation connected to the potable supply, with a follow-up on whether chemicals can be injected.
- Fire sprinkler systems, and whether they contain any additives.
- Swimming pools, hot tubs, and decorative ponds, and whether they are filled by direct connection or by hose.
- Auxiliary water sources such as private wells, storage tanks, rainwater catchment, or reclaimed water.
- Boilers, heat exchangers, radiant floor heating, and solar water heating tied to the potable line.
- Water softeners, reverse osmosis units, and other treatment equipment, with a question about whether the backwash drains through an air gap.
- Other connections: home-based businesses, dialysis machines, livestock watering, dock or pier lines, and on-site sewage pump stations.
If a backflow prevention device is already installed on your service, the form asks for its make, model, serial number, pipe size in inches, installed location, and the date it was last tested. You sign and date the bottom to certify the information is accurate. If none of the checklist items apply, most forms include a “none of the above” option to check before signing.
Commercial and industrial forms run longer because the hazards are more numerous. The EPA has noted that most cross-connections occur within commercial, institutional, or industrial plumbing systems, and that connections are frequently created without the water system operator’s knowledge.2Environmental Protection Agency. Potential Contamination Due to Cross-Connections and Backflow and the Associated Health Risks Facilities like car washes, dry cleaners, medical offices, mortuaries, and food processing plants are routinely classified as high-hazard. Many utilities require a licensed cross-connection control specialist to conduct or review the hazard assessment for commercial and industrial sites, and the specialist’s written findings often need to accompany the returned form.
Walk the Property Before You Check Any Boxes
The survey is only useful if it matches what is actually on the property, so a walk-through before you start writing is worth the time. Start at the water meter and follow the supply line into the building. Note every branch that feeds something other than a drinking faucet or a standard fixture. Outside, check hose bibs, irrigation control valves, and any piping running to a well, pond, or pool. Inside, look for boiler connections, softener hookups, and any plumbing that ties into heating or cooling equipment.
Utilities sort what they find into two hazard categories. A low-hazard cross-connection could let non-toxic but unpleasant substances back into the supply, like slightly discolored water from a heating loop. A high-hazard cross-connection could introduce genuinely dangerous material such as irrigation fertilizer, pool chemicals, or sewage from a pump station. The category determines what kind of backflow protection your utility will require.
Recording Your Backflow Device
If your walk-through finds an existing backflow assembly, copy its details straight from the device body, which is stamped or tagged with the make, model, serial number, and size. Common assemblies you might see include a Reduced Pressure Zone Assembly (RPZ), a Pressure Vacuum Breaker (PVB), a Double Check Valve Assembly (DCVA), or an Atmospheric Vacuum Breaker (AVB). The form does not usually ask you to name the type; it asks for the identifying information printed on the unit. Mismatched serial numbers or wrong pipe sizes are one of the top reasons a utility flags a survey as incomplete, so write the information down at the device rather than from memory.
Getting a Current Test Report
Most utilities require any existing backflow assembly to be tested annually by a certified tester, and the survey asks for the results of the most recent test. Standard fields include the tester’s name, certification number, and the test date. If your device has not been tested within the past 12 months, schedule a test before returning the form. Submitting a survey without current test results is one of the most common reasons utilities send it back.
Certification standards vary by state. The two credentials you will see most often are the American Backflow Prevention Association (ABPA) tester certification and the ASSE 5110 qualification. Some states accept either; others maintain their own programs. Your utility’s website or customer service line can tell you which certifications they recognize and often provides a list of approved testers.
A residential backflow test typically costs between $30 and $300 per device, depending on your location and the assembly type. The tester connects differential pressure gauges to the test cocks, measures the pressure drop across each check valve, confirms the relief valve opens at the correct differential on an RPZ, and documents pass or fail. If the device fails, the tester either repairs it on the spot or schedules a follow-up and retests. You receive a report with the readings, the result, and the tester’s credentials. Keep it. You need the data for the form, and many utilities also require the tester to submit a copy directly.
Submitting the Form
With your walk-through done and your test report in hand, filling out the survey is mostly a matter of transferring information. Check every applicable item on the hazard checklist. Enter the device details exactly as they appear on the assembly and the test report. Sign the certification at the bottom.
Submission methods depend on your utility. Online portals are increasingly common and let you upload a scanned or photographed test report with the completed form. Some utilities accept email to a dedicated compliance address. Others still require a paper form returned by mail. Whichever method applies, save a copy of everything you send and note the date submitted. If the utility provides a confirmation number or tracking receipt, keep that too.
Common reasons a survey gets rejected or delayed:
- The form says a backflow device is installed, but no current test results are attached or on file.
- The last test was more than 12 months ago, so the utility treats it as expired.
- Device information is incomplete: missing serial number, wrong pipe size, or blank location field.
- The certification signature at the bottom is missing.
After You Send It In
Utility staff review the form and categorize the property’s hazard level. If everything checks out, the property is marked compliant in the utility’s database. Some utilities send written confirmation; others simply stop sending notices.
If a problem turns up, you will receive a corrective action notice. Common outcomes are a requirement to install a backflow assembly where one is missing, upgrade an existing device to match the hazard level, or schedule an overdue test. The notice will give you a deadline, often 30 to 90 days, to finish the work and submit proof. The utility may also schedule a site inspection to verify what you reported, especially for commercial properties or when the form contains discrepancies.
Returning the survey is not a one-time task. Annual testing continues to be required for any backflow assembly, and many utilities send a reminder when a test is due. Full resurveys are less frequent, with schedules that vary by property type and jurisdiction.
If You Ignore the Form
Utilities treat an unreturned cross-connection survey as a compliance failure, and the enforcement path escalates. The first step is usually a written warning or violation notice with a final deadline. If you still do not respond, the utility can assess fines, and those fines often accrue daily until you comply. The most serious consequence is disconnection of water service. Utilities have the authority to terminate service to any property that poses a potential contamination risk to the distribution system, and refusing to complete a survey or allow an inspection is grounds for disconnection.1Environmental Protection Agency. Cross-Connection Control Manual Reconnection after a shutoff typically requires completing all outstanding corrective work, paying accumulated fines, and covering a reconnection fee.
For most residential properties without irrigation, pools, or auxiliary water sources, the form takes five minutes. Check “none of the above,” sign, send it back. For properties with a backflow device, the real work is keeping the annual test current and copying the results onto the form correctly.