Describe the PWS’s CCC Program plan, policies, or procedures at the end of the reporting year _____. Part 1: Public Water System (PWS) Identification PWS ID: PWS Name: County: Part 2: Cross-Connection Control (CCC) Program Characteristics Type of Program Currently Implemented Type of Program Check One Premises isolation only. Combination program: reliance on both premises isolation and in-premises protection. In transition from a combination program to a premises isolation-only program. Coordination with Authority Having Jurisdiction (AHJ) on Cross-Connection Issues Indicate the status of coordination with AHJs in your service area. The AHJ is the entity that enforces the Uniform Plumbing Code. Check one box in each of last three columns for each AHJ in your service area. AHJ No. Name of AHJ (e.g., the City or County Building Department) PWS currently: If Not Coordinating, did AHJ Decline to Coordinate? Coordinates with AHJ Has Written Agreement with AHJ 1 Y N Y N Y N 2 Y N Y N Y N 3 Y N Y N Y N 4 Y N Y N Y N 5 Y N Y N Y N 1 If more than 5 AHJs, attach separate sheet providing the above information. Corrective or Enforcement Actions Available to the Purveyor Type of Corrective Action Indicate Whether Available Most Often Used (check one) Denial or discontinuance of water service. Y N Purveyor installs backflow preventer and bills customer. Y N Assessment of fines (in addition to elimination or control of cross connection). Y N Other corrective actions (describe): Y N Y N
CCC Program Responsibilities Do not include enforcement action-related procedures or circumstances. CCC Program Activity Responsible Party (Check one per row) Customer Purveyor Hazard Evaluation by DOH-certified CCS Backflow preventer (BP) ownership BP installation BP initial inspection (for proper installation – all BPs) BP initial test (for testable assemblies) BP annual inspection (Air Gaps and AVBs) BP annual test (for testable assemblies) BP maintenance and repair Backflow Protection for Fire Protection Systems Please remember to enter number of days allowed if you require retrofitting. PWS coordinates with AHJ on CCC issues for fire protection systems (FPS). Y N N/A PWS coordinates with local Fire Marshal on CCC issues for FPS. Y N N/A PWS ensures backflow prevention is installed before serving new connections with FPS. Y N PWS requires retrofits to high-hazard FPS. Y (No. of days allowed: _____) N N/A PWS requires retrofits to low-hazard FPS. Y (No. of days allowed: _____) N N/A Backflow Protection for Irrigation Systems Minimum level of backflow prevention required on irrigation systems without chemical addition. Not Addressed AVB PV/SVBA DCVA RPBA PWS currently inspects AVBs upon initial installation. Y N N/A PWS currently inspects AVBs upon repair, reinstallation, or relocation. Y N N/A Used Water PWS prohibits, by ordinance, rule, policy, or agreement, the intentional return of used water (e.g., for heating or cooling) into the distribution system. Y N If not prohibited at present, date plan to prohibit. Date (mm/dd/yyyy): N/A Current number of service connections returning used water to distribution system. Backflow Protection for Unapproved Auxiliary Water Supplies1 NOT Interconnected with PWS Show the minimum backflow preventer and type of protection required for service connections with unapproved auxiliary water supplies NOT interconnected with the PWS. Check only one box per row. Existing service connections. None DCVA RPBA AG Type of protection required. None In-premises protection Premises isolation New service connections. None DCVA RPBA AG Type of protection required. None In-premises protection Premises isolation