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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH CROSS CONNECTION SURVEY REPORT FORM INSTRUCTIONS 1. This report is due annually by March 1 for the preceding calendar year pursuant to Section 1913B102(f)

How to fill out cross connection survey report

How to fill out a cross connection survey report:

1. Begin by gathering all necessary information such as the location of the survey, the date, and the name and contact information of the person conducting the survey.
2. Identify the various sources of potential cross connections, such as irrigation systems, fire sprinkler systems, and water features. List them in the appropriate sections of the report.
3. Assess the potential hazards associated with each cross connection. This may include determining the type of contaminant that could enter the potable water supply and the likelihood of it occurring.
4. Evaluate the existing control measures in place to prevent cross connections. This may involve inspecting backflow prevention devices, checking for proper piping arrangements, and reviewing maintenance and inspection records.
5. Document any deficiencies or areas of concern that are identified during the survey. Provide detailed descriptions of the issues and note any corrective actions that are necessary.
6. Make recommendations for improvement, such as installing or upgrading backflow prevention devices, implementing regular maintenance schedules, or providing training for staff members.
7. Submit the completed survey report to the appropriate authority, such as the local water utility or health department.

Who needs a cross connection survey report:

1. Water utilities: Cross connection survey reports are often required by water utilities to ensure the safety and quality of their potable water supply. These reports help them identify potential hazards, assess the effectiveness of current control measures, and make informed decisions on how to mitigate risks.
2. Industrial facilities: Industries that utilize water in their processes, such as manufacturing plants, chemical plants, and food processing facilities, may be required to conduct cross connection surveys to protect both their employees and the community from potential contamination.
3. Commercial buildings: Office buildings, shopping malls, hotels, hospitals, and other commercial establishments may need to perform cross connection surveys to comply with local regulations and ensure the safety and integrity of their water supply systems.
4. Residential properties: Homeowners and landlords may choose to conduct cross connection surveys as a proactive measure to safeguard their potable water supply and ensure the health and well-being of their families or tenants.
5. Regulatory authorities: Government agencies responsible for overseeing public health and water quality may require cross connection survey reports as part of their inspections and compliance monitoring efforts. These reports provide valuable information for regulatory assessment and enforcement actions.

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What is cross connection survey report?

Cross connection survey report is a document that identifies potential cross connections between potable water sources and non-potable sources, to prevent contamination of the drinking water.

Who is required to file cross connection survey report?

Public water systems and their customers are required to file cross connection survey reports.

How to fill out cross connection survey report?

Cross connection survey reports can be filled out by documenting all possible cross connections within a facility and implementing backflow prevention measures.

What is the purpose of cross connection survey report?

The purpose of a cross connection survey report is to protect the public water supply from contamination by ensuring that proper backflow prevention measures are in place.

What information must be reported on cross connection survey report?

Information regarding potential cross connections, backflow prevention devices, and maintenance procedures must be reported on a cross connection survey report.