Cross Connection Control Annual Report for Water Systems

Number of Service Connections:

Commercial:

Residential:

Does the water system have dual checks on the meter setters?

YesNo

If yes, do you maintain an inventory of the locations of dual check valves?

YesNo

Is there a secondary water source within the water systems jurisdiction?

YesNo

If "Yes" ...

Is the secondary water source maintained by water system?

YesNo

Is the secondary water source maintained by private entity?

YesNo

Has the water system reviewed the Authority Statement?

YesNo

Date reviewed:

Has the Authority Statement been revised or amended?

YesNo

Date reviewed:

Does the water system have a certified CCC Program Administrator?

YesNo

If "Yes" ...

Name:

Certification Number:

Expiration Date:

If "No" ...

Does the water system have an individual on staff trained in cross connection control?

YesNo

Name(s):

Backflow 101?

YesNo

Date:

Location:

Online?

YesNo

Seminar?

YesNo

Date:

Decribe Training:

Location:

Hours of Training:

Does the water system document these public awareness and education events in your records?

YesNo

If yes, how is it documented?

Date:

Type of Activity:

Number of People:

Date:

Type of Activity:

Number of People:

Date:

Type of Activity:

Number of People:

Which method(s) are used by the water system to document cross connection control records?

Computer DatabaseComputer SpreadsheetFile System

Other:

Are records maintained for Backflow Assembly Inventory

YesNo

If so, how many backflow assemblies do you have on record?

Are records maintained for high hazard air gap inventory?

YesNo

If so, how many high hazard air gaps do you have on record?

Which methods were used for documentation?

Assessment ReportsBackflow Test report formLettersPhotos

Other:

How many hazard assessments have been performed the past year?

Commercial:

Residential:

How many unprotected cross connections were located at hazard assessments in the past year?

Commercial:

Residential:

How many of these cross connections have been corrected?

Commercial:

Residential:

DW Division Menu

DEQ Menu

Instructions

Water System Information

Authority Statement (Ordinance, By-Law, Policy)

Trained Staff For Cross Connection Control

Type of Training

Public Awareness and Education

How many of the public awareness events were ...

List public awareness and education events in the past year

Record Keeping

On-Going Program and Enforcement

Agree and Submit

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