DDW-2024-009839

Cross Connection Program for Church Owned Properties with Private Water Systems
Property / Camp Name
Mantua Valley Camp

Street Address
Public Water System Number

UTAH02075

System Operator

Program Sections:
Legal Authority
Cross ConnectionEducation and Awareness
Cross Connection Training and Staff
Written Records
Appendix - Backflow / Cross Connection Evaluation Form
CrossConnectionControlFactSheet
Formoreinformationaboutthis topic,call theNaturalResources:SaltLakearea:1-801-240-4656Allotherareas:1-800-453-3860,ext.2-4656
This factsheet addresses thestepsofestablishing aCrossConnectionControlProgramfor Church owned water supplies.
Acrossconnectionisa connectionbetweenthedrinkingwater you supplyyourcustomers and a non-potablesource of water.Cross connections are dangerous because of the potentialfor backflowtooccur.Backflow
happenswhen the water in your pipes flows backwards.Thereare twocircumstances that cause water to reverse flow and go backwards.They are"backpressure" and "backsiphonage".
"Backpressure" is the reversalof flow in a systemdue toan increase in the downstream pressure above that of the supply pressure.Examples of the causes of these downstream elevated pressures
include booster pumps, thermal expansion caused by connections to boilers, and interconnections to pipes with higher pressure. "Backsiphonage" occurs when there is negative pressure
in your system.Backsiphonage can be created when there is stoppage of the water supplydue to nearby fire-fightingand repairsof breaks in thecity main.Theeffect issimilar tothe sipping
ofasoda by inhaling through a straw,whichinducesa flow intheoppositedirection.
A drinking water system that has a cross connectionto a non-potable, or untreated, source of water can become contaminatedif backpressure or backsiphonageoccurs.Cross connections need
to be identified and eliminatedby installing, testing and maintaining cross connection control devices and assemblies.Your responsibility is to identify cross connections in your system
and eliminate them or ensure that your systemis protectedfromthem.Establishing a cross connection control program for your system willhelp you protect your system from contamination.These
programs vary by state and municipality, but will generally include the followingsix(6)elements:(I)LegalAuthority,(2)EducationandAwareness,(3)TrainedStaff,(4)WrittenRecords,(5)On-goingEnforcement,and(6)Installation,TestingandInspectionofBackflow
Prevention Devices.Please contact your state primacy drinking water program, state building code or plumbing authority, or health department to identify any specific or unique elements
of the cross-connection controlprogramin your state.
The best waytoestablish this program istoassemble a loose leafnotebookwith thetabs identified and addressing each element as follows:
LegalAuthority:Underthis tab,includethepolicyDrinkingWaterSystems -Cross ConnectionControl Policythat has been adopted by the Officeof the Presiding Bishopric which authorizes yoursystemtocarryout
an effective crossconnection controlprogram.CreatedApril10,2009Cross Connect Control Fact Sheet, page 1 of 2
EducationandAwareness:Under thistab,include copiesofanyinformationthatyou distribute to employeesand others withinyour system that canhelp you identify andprevent cross connections.Theseinformation
sheets explain whatcross connections are,how they can be prevented, what types of protection are available,and how the system can be protectedfrom thermal expansionassociatedwithhot
water heatersand boilers. This informationcanbe found atyourlocalRuralWaterUser'sAssociation.Foradditionalinformationvisitwww.nrwa.organd www.epa.gov/safcwater/dwinfo.Furthermore, the
EPA's"Cross-Connection Control: A Best Practices Guide'' can be found at: www.epa.gov/safewatcr/crossconnectioncontrol.
Trained Staff:Under this tab, include crossconnection control training certificates or the time and dates that your staff was trained.At least one person in the water system's staff
must be adequately trainedin the principles of a crossconnectioncontrolprogram.
WrittenRecords:Under thistab, include: (I)aninventory ofall ofthe backflow assemblies and high hazard air gaps located in your system along with their locations; (2) assembly test resultsand
histories; and (3) inspections and assessments of high hazard air gaps.
On-goingRecords:Under this tab, include a description ofallhazard assessments conducted on your system and any backflow incidents that have occurred in your system.Be sure to document
all on-going enforcement activities and corrective actions that your system has taken. Also describe how you ensure assemblies are tested on time and how backflow incidents are corrected
and prevented.
Installation, Testing and Inspection of Backflow Prevention Devices:This item does not require aseparatetab,but it is mentionedhereas a reminder oftheobligation to install,maintain and
regularly inspect the backflow prevention devices.Records pertaining tothis item should be includedunder the tab "WrittenRecords'' discussedabove. (Please note that while this itemis
not separately named as a part of the crossconnectioncontrol program elements establishedby the Utah Department of Environmental Quality, in substance, it is included in the specifically
named elements.Further, this itemis includedas apart of theEPA's"Cross-Connection Control: A Best Practices Guide.")CreatedApril10,2009Cross Connect Control Fact Sheet, page 2 of 2
©2007byIntellectualReserve,Inc.Allrightsreserved.Printedinthe USA.English approval:x/xx.36838
4823-7357-1332.3
Date

Staff Member
Title of Training
An inventory of backflow assemblies and air gaps in the water system; including records of regular test results, inspections, and assessments.
Hazard
Risk Level (High/Low)
Protection
Date Last Tested
Property / Camp Name:

Property Number:

System Operator:

Local Water Authority:

Water System #:

Date of Survey:

Contact Name:

Phone #:

E-mail:

Y / N
Do Facilities Mangager(FM),Water System Operator, and Camp Hosts have a copy of the policies and standards?
Y / N
Is the System Operator’s spring startup inspections and testing complete?
Y / N
Has documentation sent to FM?
Y / N
Has the inventory and document service record for each item below been checked at least annually?

Backflow Device
Number of Each
Tested?
Atmospheric vacuum breaker device

N/A
Air Gap

N/A
Pressure vacuum breaker

N/A
Atmospheric vacuum breaker assembly

Y / N
Spill resistant pressure vacuum breaker assembly

Y / N
Double check valve assembly

Y / N
Reduced pressure zone principle assembly

Y / N
Y / N
Backflow devices were appropriately selected and are in-line serviceable (repairable)
Y / N
Does this property have a combined potable water and pressurized irrigation system?
Y / N
If yes is there proper cross connection control?
Y / N
Are secondary water spigots labeled "not for drinking"?
Date of last risk assessment evaluation:

Date of last sanitary survey:

Backflow and Cross Connection Evaluation Form, page 1 of 2
Backflow / Cross Connection Evaluation Form
Continued
Action Item
Estimated Completion Date
Degree of Hazard High (Health)
Low (non-Health)
1

2

3

4

5

6

Additional Comments

For more information about the Utah State Cross Connection Control Regulations see State Code R309-105-12.
Backflow and Cross Connection Evaluation Form, page 2 of 2