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Public Utilities Cross Connection Program Backflow Assessment Form *Company Name: Office Use Only *Service Address: *Meter #: *Found on utility bill **Location: **Pin: **Found at Wake Gov. Real Estate
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How to fill out backflow assessment form
How to fill out backflow assessment form:
01
Obtain the necessary form: Contact your local water utility or health department to request a copy of the backflow assessment form. Alternatively, you may find the form available for download on their website.
02
Read the instructions: Familiarize yourself with the instructions provided on the form. This will help ensure that you understand the purpose of each section and what information is required.
03
Provide contact information: Begin by filling out your name, address, and contact information. Make sure to include accurate and up-to-date details so that the authorities can reach you if necessary.
04
Identify the property: Indicate the property's address, including any unit or apartment numbers, which the backflow assessment pertains to. If the property is part of a larger complex, provide any additional information required to identify it uniquely.
05
Assess the water system: Evaluate the water system on the property. This may require inspecting the plumbing infrastructure and identifying any potential sources of backflow, such as irrigation systems or fire sprinkler systems.
06
Note existing backflow prevention devices: Check for any existing backflow prevention devices already installed on the property. If there are any, specify the type of device, location, and year of installation. Attach any supporting documentation, such as maintenance records or certifications, if requested.
07
Identify potential hazards: Determine if there are any potential cross-connections or hazardous materials on the property that could pose a risk of backflow contamination. Provide a detailed description of these hazards and their locations.
08
Plan for future prevention measures: Outline any proposed measures to mitigate backflow risks, such as installing additional backflow prevention devices, regular maintenance schedules, or staff training. Include any relevant costs or timelines associated with these plans, if applicable.
09
Submit the form: Once you have completed all the necessary sections, review the form for accuracy and completeness. Sign and date the form, as required, and submit it to the appropriate authority, following their specified submission process.
Who needs backflow assessment form:
01
Property owners: Whether you own a residential property, commercial building, or industrial facility, you may need to fill out a backflow assessment form. This includes homeowners, landlords, business owners, and property managers.
02
Local authorities: Water utilities, health departments, or other regulatory bodies responsible for ensuring water quality and safety often require property owners to complete a backflow assessment form. These authorities may use the information provided to assess potential backflow risks and enforce appropriate prevention measures.
03
Plumbing contractors: In some cases, plumbing contractors who install or repair backflow prevention devices may also need to fill out a backflow assessment form. This is typically done to document the installation or maintenance of these devices and their compliance with regulatory standards.
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What is backflow assessment form?
Backflow assessment form is a document used to assess the risk of backflow in a plumbing system.
Who is required to file backflow assessment form?
Property owners and businesses with plumbing systems that could pose a risk of backflow are required to file the form.
How to fill out backflow assessment form?
The form should be filled out by providing detailed information about the plumbing system, potential hazards, and backflow prevention devices.
What is the purpose of backflow assessment form?
The purpose of the form is to assess and mitigate the risk of backflow, which can contaminate drinking water.
What information must be reported on backflow assessment form?
Information such as the location of the plumbing system, potential backflow hazards, and details of backflow prevention devices must be reported.
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