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Cross Connection Control Annual Report for Water Systems


  1. Using your cross connection control records and documentation, please complete this form with information that applies to you water system.
  2. Submit a copy of this form to the Utah Division of Drinking Water
  3. Keep a copy for your water system cross connection control records

Water System Information

Number of Service Connections:

If "Yes" ...

Authority Statement (Ordinance, By-Law, Policy)

Trained Staff For Cross Connection Control

If "Yes" ...
If "No" ...

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

Computer DatabaseComputer SpreadsheetFile System


Assessment ReportsBackflow Test report formLettersPhotos

On-Going Program and Enforcement

How many hazard assessments have been performed the past year?

How many unprotected cross connections were located at hazard assessments in the past year?
How many of these cross connections have been corrected?

Agree and Submit

I Agree