DDW-2024-012711

Cross Connection Program for Church Owned Properties with
Private Water Systems

Program Sections:
1. Legal Authority
2. Cross Connection Education and Awareness
3. Cross Connection Training and Staff
4. Written Records
Appendix - Backflow / Cross Connection Evaluation Form

Property / Camp Name Mutual Dell Recreation
Street Address
Public Water System
Number

UTAH25075
System Operator

Cross Connection Control Fact Sheet
For more information about this topic, call the Natural Resources:
• Salt Lake area: 1-801-240-4656
• All other areas: 1-800-453-3860, ext. 2-4656

This fact sheet addresses the steps of establishing a Cross Connection Control Program for Church
owned water supplies.

A cross connection is a connection between the drinking water you supply your customers and a
non-potable source of water. Cross connections are dangerous because of the potential for
backflow to occur. Back flow happens when the water in your pipes flows backwards. There are two
circumstances that cause water to reverse flow and go backwards. They are "backpressure" and
"backsiphonage".

"Backpressure" is the reversal of flow in a system due to an 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 supply due to nearby fire-fighting
and repairs of breaks in the city main. The effect is similar to the sipping of a soda by inhaling through
a straw, which induces a flow in the opposite direction.

A drinking water system that has a cross connection to a non-potable, or untreated, source of water
can become contaminated if backpressure or backsiphonage occurs. Cross connections need to be
identified and eliminated by 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 system is protected from them. Establishing a cross connection control program
for your system will help you protect your system from contamination. These programs vary by state
and municipality, but will generally include the following six (6) elements: (I) Legal Authority, (2)
Education and Awareness, (3) Trained Staff, (4) Written Records, (5) On-going Enforcement, and (6)
Installation, Testing and Inspection of Backflow 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 control program in your state.
The best way to establish this program is to assemble a loose leaf notebook with the tabs identified
and addressing each element as follows:
Legal Authority: Under this tab, include the policy Drinking Water Systems - Cross Connection
Control Policy that has been adopted by the Office of the Presiding Bishopric which authorizes your
system to carry out an effective cross connection control program.
Created April 10, 2009 Cross Connect Control Fact Sheet, page 1 of 2

Education and Awareness: Under this tab, include copies of any information that you distribute
to employees and others within your system that can help you identify and prevent cross
connections. These information sheets explain what cross connections are, how they can be
prevented, what types of protection are available, and how the system can be protected from thermal
expansion associated with hot water heaters and boilers. This information can be found at your local
Rural Water User's Association. For additional information visit www.nrwa.org and
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 cross connection 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 trained in the principles of a cross connection control program.

Written Records: Under this tab, include: (I) an inventory of all of the backflow assemblies
and high hazard air gaps located in your system along with their locations; (2) assembly test
results and histories; and (3) inspections and assessments of high hazard air gaps.

On-going Records: Under this tab, include a description of all hazard 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 a separate tab, but it is mentioned here as a reminder of the obligation to install,
maintain and regularly inspect the backflow prevention devices. Records pertaining to this
item should be included under the tab "Written Records'' discussed above. (Please note that
while this item is not separately named as a part of the cross connection control program
elements established by the Utah Department of Environmental Quality, in substance, it is
included in the specifically named elements. Further, this item is included as a part of the
EPA 's "Cross-Connection Control: A Best Practices Guide.")

Created April 10, 2009 Cross Connect Control Fact Sheet, page 2 of 2
© 2007 by Intellectual Reserve, Inc. All rights reserved. Printed in the 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