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

    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