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Home My WebLink AboutDDW-2025-004863State of Utah Division of Drinking Water Cross Connection Control Annual Report Instructions Step 1 Using your cross connection control records and documentation, please complete this form with information that applies to your water system. Step 2 Submit a copy of this form to the Utah Division of Drinking Water Step 3 Keep a copy for your water system cross connection control records *Annual Report for the year of: _________ *Name of Person Completing Report:_________________________________________________________________ *Title or Position: _________________________________ *Email: _________________________________________ Water System Information *Water System Name:_____________________________________________________________________________ *Water System Number: _____________________________ Population Served:_____________________________ *Water System Classification: O Community O Non-Community Transient O Non-Community Non-Transient Number of Service Connections: Commercial: _________ Residential: _________ Name of individual administering & implementing the CCC program: _____________________________________________ Phone: ___________________________________ Email: _______________________________________________________ Does the water system have dual checks on the meter setters? O Yes O No If yes, do you maintain an inventory of the locations of dual check valves? O Yes O No 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? O Yes O No If "Yes" ... Is the secondary water source maintained by water system? O Yes O No Is the secondary water source maintained by private entity? O Yes O No Division of Drinking Water P.O. Box 144830 Salt Lake City, UT 84114 Phone: 801-536-4200 E-mail: grager@utah.gov Backflow.utah.gov Within the water system are there any connections to private wells? O Yes O No Does your water system have smart meters with reverse flow detection capability? O Yes O No Authority Statement (Ordinance, By-Law, Policy) Does the water system have a cross connection control Authority Statement? O Yes O No Has the water system reviewed the Authority Statement? O Yes O No Date reviewed: ____________________________________ Has the Authority Statement been revised or amended? O Yes O No Date reviewed: ____________________________________ Have you forwarded a copy of the Authority Statement to DDW? O Yes O No Is a copy of the water systems cross connection control Authority Statement available for customers to view? O Yes O No Trained Staff For Cross Connection Control Does the water system have a certified CCC Program Administrator? O Yes O No If "Yes" ... Name: ______________________________________ Certification Number: __________________________ Expiration Date: _______________________________ If "No" ... Does the water system have an individual on staff trained in cross connection control? O Yes O No Name(s):__________________________________________ _________________________________________________ Type of Training Backflow 101? O Yes O No Date: ________________________ Location: ________________________ Online? O Yes O No Seminar? O Yes O No Date: ________________________ Location: ________________________ Hours: ______________________ Describe 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? O Yes O No 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? File System Computer Database Computer Spreadsheet Other: ____________________________________ How often are your cross connection control records updated and reviewed? O Annually O Monthly O Weekly O Daily Are records maintained for Backflow Assembly Inventory? O Yes O No If so, how many backflow assemblies do you have on record? ____________________________________ Are records maintained for high hazard air gap inventory? O Yes O No If so, how many high hazard air gaps do you have on record? ____________________________________ Are records maintained for hazard assessments and inspections? O Yes O No Are records maintained for compliance correspondence with customers? O Yes O No Are records maintained for enforcement actions? O Yes O No Which methods were used for documentation? Assessment Reports Backflow Test report form Letters Photos  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 Signature: Date: "By signing, I certify the above information is correct and complete. I understand that all info may be verified by Drinking Water Staff."