2019 Cross Connection Annual Summary Report (ASR)

Instructions: Please fill out the Annual Summary Report (ASR) accurately and completely with data from 2019. Complete Report before March 31, 2020 Questions? Email: cross.connection@state.or.us Call: 971-673-0321

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ASR CONTACT

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

Phone

CUSTOMER BASE

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

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

Did you revise your Enabling Authority in 2019?*
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System Size*

Name (first and last) of CCS

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Phone
BACKFLOW PREVENTION PROGRAM PLAN The following questions are specific to the required written backflow prevention program plan as outlined in OAR 333-061-0070(9)(b).*

Does your water system have a current written backflow prevention program plan?

Does the backflow prevention plan include the following:*

1. A list of premises where health hazard cross connections exist, including, but not limited to, those listed in Table 42 (High Hazard Table)

2. Procedure for continually evaluating the degree of hazard posed by a water user's premises.*
3. Procedure for notifying the water user if a non-health hazard or health hazard is identified, and for informing the water user of any corrective action required.
4. The type of protection required to prevent backflow into the public water supply, commensurate with the degree of hazard that exists on the water user's premises.
5. A description of what corrective actions will be taken if a water user fails to comply with the water suppliers cross connection control requirements.
6. Current records of approved backflow prevention assemblies installed, inspections completed, test results, and verification of current backflow assembly tester certification.
7. A public education program about cross connection control.

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?*

If less than 70% of your RPs were tested, please provide a reason why. You may also provide any other RP related comments here.

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?*

If less than 70% of your DCs were tested, please provide a reason why. You may also provide any other DC related comments here.

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?*

If less than 70% of your PVBs were tested, please provide a reason why. You may also provide any other PVB related comments here.

CERTIFY & FINISH

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