Cross Connection Control Annual Report for Water Systems

Instructions

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

^*Annual Report for the year of:

^*Name of Person Completing Report:

^*Email:

^*Title or Position:

Water System Information

^*Water System Name:

^*Water System Number:

^*Water System Classification:

CommunityNon-Community TransientNon-Community Non-Transient

Population Served:

Number of Service Connections:

Commercial:

Residential:

Name of individual administering and implementing the CCC program:

Phone:

Email:

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

What percentage of the water system has dual check valves at the meter in your system?

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

Within the water system are there any connections to private wells?

YesNo

Does your water system have smart meters with reverse flow detection capability?

YesNo

Authority Statement (Ordinance, By-Law, Policy)

Does the water system have a cross connection control Authority Statement?

YesNo

Has the water system reviewed the Authority Statement?

YesNo

Date reviewed:

Has the Authority Statement been revised or amended?

YesNo

Date reviewed:

Have you forwarded a copy of the Authority Statement to DDW?

YesNo

Is a copy of the water systems cross connection control Authority Statement available for customers to view?

YesNo

Trained Staff For Cross Connection Control

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):

Type of Training

Backflow 101?

YesNo

Date:

Location:

Online?

YesNo

Seminar?

YesNo

Date:

Decribe Training:

Location:

Hours of Training:

Public Awareness and Education

How many public awareness and education events were provided by the water system in the past year in the topic of cross connection control or backflow prevention?

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

YesNo

If yes, how is it documented?

How many of the public awareness events were ...

Online:

Public Meetings:

Brochures:

Staff Training:

Consumer Confidence Report:

Other? Describe:

List public awareness and education events in the past year

Date:

Type of Activity:

Number of People:

Date:

Type of Activity:

Number of People:

Date:

Type of Activity:

Number of People:

Record Keeping

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

Computer DatabaseComputer SpreadsheetFile System

Other:

How often are your cross connection control records updated and reviewed?

AnnuallyMonthlyWeeklyDaily

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?

Are records maintained for hazard assessments and inspections?

YesNo

Are records maintained for compliance correspondence with customers?

YesNo

Are records maintained for enforcement actions?

YesNo

Which methods were used for documentation?

Assessment ReportsBackflow Test report formLettersPhotos

Other:

On-Going Program and Enforcement

How many backflow assemblies have been tested the past year?

How many high hazard air gaps have been inspected the past year?

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:

Agree and Submit

By clicking the Submit button, you certify that the information in this report is accurate. You understand that any of the information might be verified by Drinking Water Staff

I Agree

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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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