Attachment 2 - Backflow Incident Form 331-457-F.doc

DOC document 233 KB Posted

Attached to
Water and Sewer Operator Services at Walla Walla VAMC Federal contract opportunity
Solicitation number
36C26025Q0675
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 20

About this file

Written by GovTribe AI ·

The document is a Backflow Incident Report Form used for documenting cross-connection control and backflow events in public water systems. The comprehensive form captures detailed information about a specific backflow incident, including the public water system details, incident discovery method, contaminant type, extent of contamination, source of contaminant, distribution system pressure conditions, and backflow preventer information. The form requires documentation of corrective actions, agency notifications, and potential impacts such as affected connections, population at risk, and water quality complaints.

The related federal contract opportunity is a solicitation (36C26025Q0675) for Water and Sewer Operator Services at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. The solicitation requires contractors to submit quotes via email to Adam Hill by 08/22/2025, with a complete quote package including a signed SF1449, acknowledgement of amendments, DUNS/UEI and CAGE code, and firm-fixed price quotes. The contract involves creating and implementing a Water Management Plan and providing overall water system management and testing services for the Veterans Health Administration.

View the file

Other files for this federal contract opportunity

Other files attached to Water and Sewer Operator Services at Walla Walla VAMC, newest first.
File Type Posted
36C26025Q0675 0004.pdf PDF
36C26025Q0675_AMENDED.pdf PDF
36C26025Q0675 0001 (1).pdf PDF
36C26025Q0675 0003.pdf PDF
36C26025Q0675 0002.pdf PDF
Attachment 2-Meter Survey Summary.xlsx XLSX spreadsheet
Attachment 1-PWS August 2025 Revision 1.pdf PDF
Attachment 7 - Walla Walla Wage Determinations.txt TXT text file
Attachment 8 - Site Visit Instructions.pdf PDF
Attachment 6 - 2012 Water System Plan .pdf PDF
Attachment 5 - City of Walla Walla Wastewater Permit.pdf PDF
36C26025Q0675.pdf PDF
Attachment 1 - All Water Testing.xlsx XLSX spreadsheet
Attachment 4 - QASP List.pdf PDF
Attachment 3 - Current Campus Inventory.pdf PDF
Show all 15

On GovTribe

Work with this file on GovTribe

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Cross-Connection Control Program

BACKFLOW INCIDENT REPORT FORM

Note: Use this form to comply with WAC 246-290-490(8)(g).

Part 1: Public Water System (PWS) Information

PWS ID:
PWS Name:
County:

Part 2: Backflow Incident Information

A. Incident Identification

Incident date:
Time of incident:
Incident ID (DOH use):

B. Information on Premises where Backflow Originated

Name of premises:

Premises physical address:

City: , FORMDROPDOWN

Zip:

Premises type: non-residential FORMCHECKBOX residential FORMCHECKBOX

Premises category/description (Table 9 category*, if applicable):

Most recent hazard evaluation prior to incident (mm/dd/yyyy): None FORMCHECKBOX

PWS’s assessed hazard level: FORMDROPDOWN

Premises isolation required by PWS? Yes FORMCHECKBOX No FORMCHECKBOX

Type of backflow preventer required by PWS: FORMDROPDOWN

PWS relies on in-premises protection? Yes FORMCHECKBOX

Other hazard evaluation information:

*See WAC 246-290-490(4)(b)(i).

C. Method of Discovery of Backflow

How the backflow was discovered (check all that apply):
Direct observation ……………….

Meter running backwards ………..

Water use decrease ……………… Disinfectant residual monitoring ...

Water quality monitoring ………..

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Water quality complaint …………… Illness/injury complaint …………… Result of Investigation ………………...

Other (Describe):

FORMTEXT

FORMCHECKBOX

FORMCHECKBOX

Incident reported to the public water system by:
PWS Personnel FORMCHECKBOX

Premises Owner/Occupant FORMCHECKBOX Other PWS Customer FORMCHECKBOX

Backflow Assembly Tester FORMCHECKBOX Other (Specify):

D. Contaminant Information

Contaminant type (check all that apply):
Microbiological FORMCHECKBOX

Chemical FORMCHECKBOX Physical FORMCHECKBOX

Describe contaminant (for example, the organism name, chemical, etc.). Please attach lab analysis or MSDS, if available.

E. Extent and Effects of Contamination

Estimated extent of contamination:
Contained within premises FORMCHECKBOX

Entered PWS distribution system FORMCHECKBOX

Estimated number of connections affected:
Residential Non-residential
Estimated population affected or at risk:
Residential Non-residential
Number water quality complaints:
Describe water quality complaints:
Number illnesses reported:
Describe illnesses/irritation (specific illnesses, if known):

Number physical injuries(e.g. burns) or irritation(e.g. rashes) cases reported:

Part 3: Cross-Connection Control Information at Backflow Site

A. Source of Contaminant

Source of contaminant or fixture type (check all that apply):
Air conditioner/heat exchanger …..…

Auxiliary water supply ……………...

Beverage machine ……………..……

Boiler, hot water system ……..….….

Chemical injector/aspirator …….…...

Fire protection system …………..…..

Irrigation system (PWS supplied) …..

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Industrial/commercial process water/fluid……………………….

Medical/dental fixture ………..……

Reclaimed water system………..…..

Swimming pools, spa ….……..…….

Wastewater (sewage) system …..…..

Other (specify): ……….…….

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

B. Distribution System Pressure Conditions in the Vicinity of the Backflow Incident

Type of backflow:
Backsiphonage FORMCHECKBOX

Backpressure FORMCHECKBOX

Typical distribution system pressure in vicinity of incident (if range, enter lower end of range): psi

Main/pressure status at time of incident (check all that apply):
Normal ……………………………....

Main break …………………

Fire fighting …………………………

Other high usage …………………….

Power outage …………………………

FORMCHECKBOX

Source/plant outage …………………

Scheduled water shutoff by PWS …...

Unscheduled/emergency shutoff ……

Unknown ...……………………

Other (specify)

FORMCHECKBOX

FORMCHECKBOX

Describe causes and circumstances leading to backflow:

C. Backflow Preventer Information/Installation/Approval Status at Site of Backflow

Complete the tables in C and D for the premises isolation preventer for either of the following situations:

· If a premises isolation backflow preventer is installed and the contaminant entered the PWS distribution system.

· If the premises isolation assembly is the only backflow preventer at the site.

In all other cases, complete tables in C and D for the in-premises backflow preventer installed at the fixture. If more than one backflow preventer was involved in the backflow incident, copy tables C and D and complete them for the additional preventer(s).

If no backflow preventer was installed at the time the incident occurred, check this box FORMCHECKBOX and go directly to Part 4. Don’t fill out the tables below (in C and D).

Backflow preventer information:

Type installed: FORMDROPDOWN Installed for: FORMDROPDOWN

Make: Model: Size: Serial number: Date installed:

Installation status (check all that apply):
Properly installed/plumbed FORMCHECKBOX

Improperly protected bypass present FORMCHECKBOX Improperly installed/plumbed FORMCHECKBOX If so, explain:

Commensurate with assessed degree of hazard?
Yes FORMCHECKBOX

No FORMCHECKBOX

If not, explain:

DOH/USC-approved at time of backflow incident?
Yes FORMCHECKBOX

No FORMCHECKBOX

If not, approved when installed? Yes FORMCHECKBOX

D. Backflow Preventer Inspection/Testing Information at Site of Backflow

Most recent inspection/test information prior to backflow incident. Attach test report(s), if available.
No test report on record ….................................................. FORMCHECKBOX

Date tested/inspected:

Passed test/inspection without repairs ………………… Failed initial test/inspection, passed after repair ……… Failed test/inspection, no repairs made ………………..

FORMCHECKBOX

Inspection/test information after backflow incident [per WAC 246-290-490(7)(b)]. Attach test report.
Not tested/inspected …...................................................
FORMCHECKBOX

Date tested/inspected:

Passed test/inspection without repairs ………………… Failed initial test/inspection, passed after repair……….

Failed test/inspection, no repairs made………………...

FORMCHECKBOX

Preventer failure information , if applicable (check all that apply):
Fouled check ……………….

Debris ……………………… Weather-related damage …...

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Damaged seat ….

Other:

FORMCHECKBOX

If preventer failed inspection/test, did failure allow backflow?
Yes FORMCHECKBOX

If yes, explain:

Part 4: Corrective Action/Notifications

Action taken by PWS to restore water quality (check all that apply):
None ………………………

Flushed/cleaned mains …… Flushed/cleaned plumbing… Disinfected mains ………… Disinfected plumbing ……...

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Other treatment (describe):

Replaced mains ………… Replaced plumbing ……..

Other:

FORMCHECKBOX

FORMCHECKBOX

Action ordered by PWS to correct cross-connection (check all that apply):

None ……………….……… Eliminate cross-connection...

Remove by-pass …………...

Install new preventer …

For premises isolation For fixture protection

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Change existing preventer

Repair/replumb …..…… Reinstall correctly … Replace with same type Upgrade type ........…….

Other:

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Action ordered accomplished?
Yes FORMCHECKBOX

Date: FORMDROPDOWN

If no, explain:

Agency notifications per WAC 246-290-490(8)(f) (check all that apply):
DOH FORMCHECKBOX

Local Health Agency FORMCHECKBOX Local Adm. Authority FORMCHECKBOX

Issued by end of next business day: FORMDROPDOWN

Notifications of consumers in area of incident (check all that apply):
Population at risk FORMCHECKBOX

Public notification (PN per DOH regs.) FORMCHECKBOX

Boil Water Advisory FORMCHECKBOX Other (describe):

Other enforcement/corrective actions (describe):

Part 5: Cost of Backflow Incident (optional)

Item
PWS Personnel Hours Expended
Cost to PWS ($)
Cost to Premises Owner ($)
Investigation
Restoration of water quality
Correction of cross-connection situation
Litigation and/or settlement
Other not included in above

Part 6: Further Information/Documentation Additional information about this incident such as pictures, sketches, newspaper/journal articles, water quality analyses, epidemiological reports, etc. would be helpful. Information may be in electronic form or hard copy.

Part 7: Form Completion Information Note: Form should be completed by a person currently certified as a Cross-Connection Control Specialist.

I certify that the information provided in this Backflow Incident Report is complete and accurate to the best of my knowledge.

CCC Program Mgr. Name (print):
Title:
Signature:
CCS Cert. Number:
Date:
Phone:
E-mail:

I have reviewed this report and certify that the information is complete and accurate to the best of my knowledge.

PWS Mgr./Representative Name (Print):
Title:
Signature:
Op. Cert. Number:
Date:

Please send completed backflow incident form:

By mail to:

Washington State Department of Health

Office of Drinking Water – CCC Program Manager

P O Box 47822

Olympia, WA 98504-7822

By email to: cccprogram@doh.wa.gov

Please send questions, comments, or suggestions about this form to us at the address above or e-mail them to cccprogram@doh.wa.gov For people with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711).

DOH 331-457 (Updated 4/18/18)

File details come from the government source that posted it. Updated .