2022 Cross Connection Annual Summary Report (ASR)

Instructions: Please fill out the Annual Summary Report (ASR) accurately and completely with data from 2022. Complete Report by March 31, 2023

Questions? Email: cross.connection@dhsoha.state.or.us Call: 971-673-0321

Water System Name and PWS ID#

System Size

Large System, 300+ connections

Small System, 1-299 connections

ASR CONTACT

If there are questions about this report, who should we contact?

Name

Email Address

Contact Phone Number

Phone

CUSTOMER BASE

Who does your water system serve? Count each service connection only once, include connections with and without a backflow assembly.

Residential Connections

High Hazard Connections

Other Connections

ENABLING AUTHORITY

An ENABLING AUTHORITY is required for all community water systems. If you have not submitted an enabling authority to the State, please complete one and attach below. Don't know if the State has a copy? Check Data Online www.yourwater.oregon.gov, to see if we have one!

Does the State Already have an Enabling Authority on file for your water system?

Not sure? Check data online www.yourwater.oregon.gov

Yes

No, please attach a copy below

Did you revise your Enabling Authority in 2022?

Yes, attach the revised copy below

Upload your New or Edited Enabling Authority

Drop your files here

ASSEMBLY DATA

Reduced Pressure Backflow Prevention Assemblies

(RP, RPBA, & RPDA) If there are no RPs installed in your water system, answer 'No' to the first question and move on to the double check section.

Are there any RPs installed in your water system?

Yes

Double Checks Backflow Prevention Assemblies

(DC, DCVA, & DCDA) If there are no DCs installed in your water system, answer 'No' to the first question and move on to the pressure vacuum breaker section.

Are there any DCs installed in your water system?

Yes

Pressure Vacuum Breaker Assemblies

(PVB, PVBA, & SVBA) If there are no PVBs installed in your water system, answer 'No' to the first question and move on to the Certify and Finish section below.

Do you have any PVBs installed in your water system?

Yes

CERTIFY & FINISH

I certify the information provided is true to the best of my knowledge. Providing false information may result in penalties to the individual and to the water system.

Send me a copy of my responses

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