Attachment 30 - 668-16-110_Cross-Connection Control Plan FINAL .pdf

12720 E. Nora Avenue, Suite A Spokane Valley, Washington 99216 Ph. (509) 921-0290 Fax (509) 921.1788 cascade-earth.com

Cross-Connection Control Plan Mann-Grandstaff Veteran Affairs Medical Center

Spokane, Washington

September 2018

Disclaimer: The contents of this document are confidential to the intended recipient at the location to which it is addressed. The contents may not be changed, edited, and/or deleted. The information contained in this document is only valid on the date indicated on the original project file report retained by CES. By accepting this document, you understand that neither CES nor its parent company, Valmont Industries, Inc. (Valmont) accepts any responsibility for liability resulting from unauthorized changes, edits, and/or deletions to the information in this document.

Cross-Connection Control Plan Mann-Grandstaff Veteran Affairs Medical Center Spokane, Washington

Prepared For: Mr. William Wilson, AIA William Wilson Architects, PC 1022 SW Salmon Street, Suite 350 Portland, OR 97205

Prepared By: Cascade Earth Sciences 12720 E. Nora Avenue, Suite A Spokane Valley, Washington 99216

(509) 921-0290

Author(s): John W. Roberts, CCS, Field Technician David Sullivan, Staff Scientist

Reviewed By: Greg L. Thurman, P.E., Principal Engineer

Report Date: September 27, 2018

Project Number: 2018230008

Submitted By:

Greg L. Thurman, P.E., Principal Engineer

GLT

Text Box Exp. 07/03/2020

CES – Spokane Valley, WA Mann-Grandstaff VAMC | Control Plan Doc: 2018230008 Cross-Connection Ctrl Plan.docx September 2018 | Page iii

CONTENTS

1.0 REQUIREMENT FOR PROGRAM

2.0 PROGRAM OBJECTIVES

3.0 SUMMARY OF PROGRAM DECISIONS

4.0 REQUIRED ELEMENTS OF PROGRAM

4.1 Element 1 - Establishment of CCC Program

4.2 Element 2 - Cross-Connection Hazard Assessment

4.3 Element 3 - Hazard Elimination

4.4 Element 4 - Qualified Personnel

4.5 Element 5 - Inspection Requirements

4.6 Element 6 - Testing Quality Assurance Program

4.7 Element 7 - Response Plan

4.8 Element 8 - Education and Awareness

4.9 Element 9 – Record Keeping

4.10 Element 10 - Reclaimed Water

5.0 OTHER PROVISIONS

6.0 RELATIONSHIP TO OTHER PLANNING AND PROGRAM OPERATIONS

APPENDICES

Appendix A. Legal Instrument

Appendix B. Backflow Inspection and Testing Field Sheets

Appendix C1. Example Materials

Appendix C2. Cross-Connection Education Records

Appendix D1. Cross-Connection Activities Report

Appendix D2. Cross-Connection Annual Report

Appendix D3. Backflow Incident Report

Appendix D4. Exceptions to High-Health Hazard Premises

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1.0 REQUIREMENT FOR PROGRAM

The Mann-Grandstaff Veteran Affairs Medical Center (MGVAMC) hereinafter referred to as “the

Purveyor,” has the responsibility to protect the public water systems from contamination due to cross-connections. A cross-connection may be defined as "Any actual or potential physical connection between a potable water line and any pipe, vessel, or machine that contains or has a probability of containing a non-potable gas or liquid, such that it is possible for a non-potable gas or liquid to enter the potable water system by backflow.”

All public water systems are required to develop and implement cross-connection control (CCC) programs. The CCC requirements are contained in Washington Administrative Code (WAC) 246-

290-490 of the Group A Drinking Water Regulations. The minimum required elements of a CCC program are as follows:

1. Establishment of legal authority and program policies;

2. Evaluation of premises for cross-connection hazards;

3. Elimination and/or control of cross-connections;

4. Provision of qualified personnel;

5. Inspection and testing of backflow preventers;

6. Quality control of testing process;

7. Response to backflow incidents;

8. Public education for consumers;

9. Record keeping for CCC program; and

10. Special requirements for reclaimed water use.

Other requirements of a CCC program include:

1. Coordination with the Local Administrative Authority (LAA), i.e. the local building or plumbing official, regarding CCC activities;

2. Inclusion of a written CCC program in the Water System Plan (WSP) or Small Water

System Management Program (SWSMP); and

3. Prohibition of the intentional return of used water.

2.0 PROGRAM OBJECTIVES

The objectives of the CCC program are to:

1. Reasonably reduce the risk of contamination of the source of supply and water distribution system; and

2. Comply with the applicable plumbing code and other regulations pertaining to the construction and operation of the Purveyor’s facilities.

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3.0 SUMMARY OF PROGRAM DECISIONS

The following table summarizes the major policy and program decisions adopted for the

MGVAMC Water System.

Decision Item

Decision

(Check one option per item)

1. Assessment and Re-Assessment of Cross-Connection Hazards (Element 2)

a. By purveyor’s certified CCS

b. By consultant CCS on contract to water system

c. By another agency’s CCS (via an inter-agency agreement)

2. CCS Option - purveyor’s CCC Program Management (Element 4)

a. By purveyor’s certified CCS

b. By another agency’s CCS (via an inter-agency agreement)

c. By consultant CCS on contract to water system

3. Testing of Assemblies (Element 5)

a. By purveyor’s staff or purveyor employed certified BAT

b. By customer employed (contractor) BAT

4. Extent of Coordination with Local Administrative Authority (Other

Provisions) [WAC 246-290-490 (2)(d)]

a. Information exchange X

b. Interaction

c. Joint program

d. Not applicable at this time (no new facilities construction or remodeling)

4.0 REQUIRED ELEMENTS OF PROGRAM

The following program elements are required parts of a CCC program (WAC 246-290-490).

4.1 Element 1 - Establishment of CCC Program

Purpose: Adoption of a written legal instrument authorizing the establishment and implementation of a CCC program.

The Purveyor is the owner and operator of all facilities on the premises. By stated policy, the

Purveyor is authorized and mandated to protect the water system from contamination via cross-connections. An example legal instrument authorizing the Purveyor to develop and implement a

CCC program is provided as Appendix A. MGVAMC may use this as a template or insert another instrument, if applicable.

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4.2 Element 2 - Cross-Connection Hazard Assessment

Purpose: Development and implementation of procedures and schedules for evaluating new and existing service connections to assess the degree of hazard.

Existing Facilities/Systems - The Purveyor will ensure that a Department of Health (DOH) certified cross-connection control specialist (CCS) conducts an initial cross-connection hazard evaluation of the MGVAMC Water System in association with adoption of this CCC program.

Program Adoption Date: ____________ Initial Hazard Survey Date: _____________

New Facilities/Systems – The Purveyor will ensure that a DOH-certified CCS conducts an initial cross-connection hazard evaluation before water service is provided to any new facilities, plumbing system upgrades, equipment installations, etc. served by the water system. This may be completed by updating and/or adding to the initial cross-connection hazard evaluation.

Periodic Resurveys – The Purveyor will ensure that a DOH-certified CCS periodically resurveys for cross-connection hazards at MGVAMC Water System. Resurveys will be conducted:

1. Every 3 years after the initial hazard survey; and

2. Upon any changes in use of the premises, plumbing or distribution facilities.

4.3 Element 3 - Hazard Elimination

Purpose: Development and implementation of procedures and schedules for elimination and/or control of cross-connections.

The following procedures apply to all new and existing buildings or areas of water use in the

MGVAMC Water System:

1. Mandatory Premises Isolation for High-Hazard Buildings, Facilities, or Systems – The

Purveyor will ensure that water services to all buildings, facilities, or systems of the type described in Table 9 of WAC 246-290-490 (i.e., high hazard) are isolated by a DOH-approved reduced pressure backflow assembly (RPBA).

2. Compliance with Uniform Plumbing Code/Additional Premises Isolation Requirements –

The Purveyor will ensure that all buildings or areas of water use:

a. Comply with the current plumbing code (amended for Washington) adopted by the State

Building Code Council; and

b. Be isolated with an approved double check valve assembly (DCVA), where the CCS believes the plumbing code does not provide protection commensurate with the assessed degree of hazard.

3. Plumbing/Water System Design – The Purveyor will ensure that the design of the plumbing and/or water system incorporates DOH-approved backflow prevention assemblies appropriate for the degree of hazard assessed by the Purveyor’s CCS. Initial plumbing/water system design and subsequent design modifications will be subject to review by a DOH-certified CCS for cross-connection hazards.

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4. Approved Backflow Assemblies – The Purveyor will ensure that DOH-approved backflow prevention assemblies protect the public water system from contamination. DOH-approved assemblies are assemblies that appear on DOH's published list of Backflow Prevention

Assemblies Approved for Installation in Washington State. The Purveyor will keep on file documentation regarding the approval status of all backflow assemblies installed to protect the public water system.

5. Installation Standards – The Purveyor will ensure that all approved backflow preventers are installed in:

• The orientation for which they are approved;

• A manner and location that facilitates their proper operation, maintenance, and testing or inspection, and in compliance with safety regulations;

• A manner and location that protects them from flooding and freezing; and

• In accordance with the installation standards outlined in the most recently published editions of the PNWS-AWWA Cross-Connection Control Manual, or the USC-

FCCCHR Manual Of Cross-Connection Control, unless the manufacturer’s requirements are more stringent.

4.4 Element 4 - Qualified Personnel

Purpose: Provision of qualified personnel, including at least one person certified as a CCS, to develop and implement the cross-connection control program.

1. Program Administration – The Purveyor or his authorized agent is responsible for administration of the CCC program.

2. DOH-Certified CCS – The Purveyor will employ, or have available on staff, at least one person certified by DOH as a CCS to develop and implement the CCC program. When no staff or employees are qualified, the Purveyor will retain a DOH-certified CCS on contract to provide the necessary expertise and services.

3. CCS Duties – The Purveyor will ensure that a DOH-certified CCS is trained and capable of completing the following:

• Performing CCC hazard evaluations;

• Determining the type of backflow preventer to be installed;

• Inspecting backflow preventers (to ensure protection is provided commensurate for the degree of hazard, for correct installation and for approval status);

• Reviewing assembly test reports;

• Reporting and investigating backflow incidents; and

• Completing reports (Annual Activities, Program Summary, and Exception Reports) required by WAC 246-290-490 and submitting them upon request to DOH.

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4. Current Management Information – The following tables show information related to the

CCC Administrator and the CCS(s) currently responsible for development, implementation, and oversight of the Purveyor’s CCC program.

Name of Program Admin

Address

City, State, Zip

Telephone Number

Name of CCS

Address

City, State, Zip

Telephone Number

CCS Certification Number

4.5 Element 5 - Inspection Requirements

Purpose: Development and implementation of procedures to ensure that approved backflow preventers are inspected and/or tested (as applicable).

1. Backflow Preventer Inspection and Testing – The Purveyor will ensure that all backflow preventers in the MGVAMC Water System are inspected and tested in accordance with

WAC 246-290-490. The Purveyor will arrange to have all backflow preventers inspected and tested (if applicable):

• At the time of installation;

• Annually after installation (minimum frequency) or more frequently;

• After a backflow incident; and

• After an assembly is repaired, reinstalled, or relocated (or air gap re-plumbed).

2. DOH-Approved Test Procedures – Per WAC 246-290-490 (7)(d), the Purveyor will ensure that all assemblies protecting the public water system from contamination are tested in accordance with DOH-approved field test procedures.

Example Backflow Preventer Inspection and Testing Field Sheets are provided in Appendix B for documentation purposes.

4.6 Element 6 - Testing Quality Assurance Program

Purpose: Development and implementation of a backflow prevention assembly testing quality control assurance program.

1. DOH-Certified Backflow Assembly Tester (BAT) – The Purveyor will ensure that only a

DOH-certified BAT tests all backflow assemblies that protect the public water system from contamination.

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2. BAT Documentation Requirements – Prior to engaging a BAT to test assemblies within the water system, the Purveyor will require the tester to document that he/she:

a. Is currently certified by DOH as a BAT;

b. Has appropriate assembly testing equipment (make, model and serial number); and

c. Has had the testing equipment verified for accuracy and/or calibrated within the past 12 months.

3. Quality Assurance – The Purveyor’s CCS will review, within 30 days of receipt, the inspection/test report forms (Appendix B) submitted by the BAT and follow-up on any reports that are found to be deficient in any way.

4.7 Element 7 - Response Plan

Purpose: Development and implementation (when appropriate) of procedures for responding to backflow incidents.

1. Backflow Incident Response Plan – The Purveyor will develop a site-specific Backflow

Incident Response Plan in consultation with the Purveyor’s CCS when a deficiency is discovered. It will reference and complement the MGVAMC Water System’s overall emergency plan.

The incident response plan will include, but not be limited to:

• Notification of affected users (employees, occupants, etc.);

• Notification and cooperation with other agencies, such as DOH, the Local

Administrative Authority, and the local health jurisdiction;

• Identification of the source of contamination;

• Isolation of the source of contamination and the affected area(s);

• Provision of alternate supplies of drinking water;

• Cleaning, flushing, and other mitigation measures; and

• Corrective action to prevent future occurrences.

2. Technical Resources – The Purveyor will use the manual, Backflow Incident Investigation

Procedures, First Edition, 1996, published by the PNWS-AWWA as a technical resource and/or supplement to the Backflow Incident Response Plan.

4.8 Element 8 - Education and Awareness

Purpose: Development and implementation of a cross-connection education program.

1. Employee Education Program – An employee education program will consist of distribution of CCC-related educational material (handouts) to (and/or holding special cross-connection classes for) staff and other water users as appropriate. The education program will emphasize the responsibility of the water users in preventing contamination of the water supply. Information distributed will include the following subjects (as applicable):

a. Cross-connection hazards in general;

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b. Cross-connection hazards typical to the Purveyor’s premises;

c. Irrigation system hazards and corrective actions;

d. Fire sprinkler cross-connection hazards;

e. Importance of annual inspection or testing of backflow preventers; and

f. Thermal expansion in hot water systems when backflow assemblies are used.

2. Educational Materials – The Purveyor may adapt existing educational materials from organizations such as PNWS-AWWA, ABPA, SRC4, and The Western Washington Cross-

Connection Prevention Professionals, so that the contents are applicable/relevant to the

Purveyor’s water system. Sample educational materials are provided in Appendix C1.

3. Frequency – The Purveyor will annually distribute information brochures to (or hold special classes for) new staff, water users, and/or occupants that could inadvertently create cross-connections in the Purveyor’s water system.

4. Employee Education Implementation – The Purveyor will document who has received employee education information to document who the Purveyor has educated, by what means, and when. An example table for recording this information is provided in Appendix

C2, or the Purveyor may use an existing documentation system.

4.9 Element 9 – Record Keeping

Purpose: Development and maintenance of cross-connection control records.

1. Required CCC Records – The Purveyor will maintain records of the following types of information:

a. CCC hazard evaluation results;

b. Backflow preventers required by the CCS to protect the public water system (may include both premises isolation and in-premises preventers);

c. Air gap location, installation and inspection dates, inspection results, and name of person conducting inspections;

d. Backflow assembly location, description (type, manufacturer, make, model, size, and serial number), installation, inspection and test dates, test results, and person performing tests; and

e. Information on atmospheric vacuum breakers used for irrigation system applications, including manufacturer, make, model, size, dates of installation and inspections, and person performing inspections.

2. CCC Reports Required to be Prepared and Submitted – The Purveyor will prepare the following required reports and submit them to DOH as indicated. Copies of standard report forms are provided in Appendices D1-D4:

a. CCC Program Activities Annual Summary Report: Complete for each calendar year and send to DOH when requested.

b. CCC Program Summary Information Report: Complete and submit when requested by DOH or when there are significant policy changes to the CCC program.

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c. Backflow Incident Reports: Complete and submit to DOH with the CCC Program

Activities Annual Summary Report unless otherwise requested by DOH.

d. Exceptions to Mandatory Premises Isolation Report (if applicable): Complete one report for each exception granted in a calendar (reporting) year and submit to DOH with the CCC Program Activities Annual Summary Report.

3. CCS Review – The Purveyor’s CCS will complete and/or review the CCC reports for accuracy.

4.10 Element 10 - Reclaimed Water

Purpose: Additional cross-connection control requirements for reclaimed water.

At this time, the MGVAMC Water System does not receive or distribute reclaimed water. In the event that reclaimed water use is proposed within the system service area, the Purveyor will incorporate into the CCC program and comply with all CCC requirements mandated by the permitting authority in accordance with Chapter 90.46 Revised Code of Washington.

5.0 OTHER PROVISIONS

1. Coordination With Local Administrative Authority: Both WAC 246-290-490 and the

Uniform Plumbing Code (as amended for Washington) require coordination between purveyors and the Local Administrative Authority in all matters concerning cross-connection control.

a. Identification of Local Administrative Authority (LAA) – The LAA that enforces the plumbing code for the premises served by the Purveyor is the Spokane County Building and Planning Department, David Jensen, 1026 W Broadway Ave, Spokane, Washington, (509) 477-7122.

b. Coordination with LAA – A copy of this CCC program was submitted to the Spokane

County Building and Planning Department on _________.

c. Description of Coordination with LAA – The Purveyor coordinates with the LAA for information sharing purposes.

d. Delineation of Responsibilities – The Purveyor is responsible for all CCC activities in the MGVAMC Water System.

e. Notification of Local Administrative Authority – The Purveyor will inform the LAA when there is a:

• Change in plumbing that requires a plumbing permit;

• Change in the use of any part of the premises that alters the cross-connection hazard level; or

• Backflow incident.

2. Prohibition of Return of Used Water: The water system must prohibit the intentional return of used water to the Purveyor’s distribution system per WAC 246-290-490 (2)(d).

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a. Definition – Used water is defined as water that has left the control of the Purveyor.

b. Used Water Policies – Since the Purveyor owns both the water supply facilities and the plumbing systems, the water has not, technically, left the control of the Purveyor.

However, for protection of the drinking water quality and the health of the employees/building occupants, the Purveyor will institute the following policies:

• Plumbing design or changes will not allow water that has been used for such purposes as heating or cooling to be returned to the drinking water system.

• Buildings and facilities with two or more water service connections that are internally connected such as to provide a flow-through condition will have each service isolated by either an RPBA or DCVA, depending upon the level of hazard assessed by the Purveyor’s CCS.

6.0 RELATIONSHIP TO OTHER PLANNING AND PROGRAM

OPERATIONS

The Purveyor will consider the impacts of the CCC program upon the planning and operations requirements of the MGVAMC Water System. Such considerations include, but are not limited to, ensuring that:

1. The design of the water distribution system (and plumbing system) provides for expected head losses resulting from installation of backflow assemblies.

2. The CCC program personnel are consulted in the design of water and wastewater treatment facilities and when proposals are made to receive or distribute reclaimed water.

3. Operations under normal and abnormal conditions do not result in excessive pressure losses.

4. Cross-connection issues are considered in water quality investigations.

5. Adequate financial and administrative resources are provided to carry out the CCC program.

APPENDICES

Appendix A. Legal Instrument

Appendix B. Backflow Inspection and Testing Field Sheets

Appendix C1. Example Materials

Appendix C2. Cross-Connection Education Records

Appendix D1. Cross-Connection Activities Report

Appendix D2. Cross-Connection Annual Report

Appendix D3. Backflow Incident Report

Appendix D4. Exceptions to High-Health Hazard Premises

Appendix A.

Legal Instrument

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LEGAL INSTRUMENT FOR A NON-COMMUNITY WATER SYSTEM

CROSS-CONNECTION CONTROL PROGRAM

Resolution No. ________

Cross-Connection Control Policy

Finding of Fact:

Whereas it is the responsibility of a water purveyor to provide water that meets Washington State water quality standards to all consumers occupying or visiting the Purveyor’s premises;

Whereas it is the water purveyor's responsibility to prevent the contamination of the public water system from the source of supply (i.e., to the customer's connection to the service pipe or meter);

Whereas the Purveyor also owns the facilities and the plumbing systems that deliver the water to the consumers;

Whereas it is a requirement of the Washington State Department of Health for the Purveyor to establish a cross-connection control program satisfactory to DOH;

Now be it resolved that the Mann-Grandstaff Veteran Affairs Medical Center, hereinafter referred to as “the Purveyor”, establishes the following policy to protect the Purveyor-owned water system and plumbing facilities from the risk of contamination. For public health and safety, this policy shall apply equally to all new and existing facilities.

A. Definitions

Unless otherwise defined, all terms used in this resolution pertaining to cross-connection control have the same definitions as those contained in WAC 246-290-010 of the Washington State

Drinking Water Regulations and Chapter 2 of the Uniform Plumbing Code as amended for

Washington State (Chapter 51-56 WAC).

B. Administrative Provisions

1. The Purveyor shall engage the services of a Department of Health (DOH) certified cross-connection control specialist (CCS), by employment or by contract, to develop, implement, and be in responsible charge of the Mann-Grandstaff Veteran Affairs Medical Center Water

System’s CCC program.

2. The Purveyor, under the direction of the CCS as provided for in B-1, shall prepare a written

CCC program plan to implement the requirements of this resolution. The written CCC program plan will be consistent with this resolution and shall comply with the requirements of Chapter 246-290 WAC (Group A Drinking Water Regulations) and with Chapter 51-56

WAC (Uniform Plumbing Code as amended for Washington).

3. The Purveyor will use the most recently published editions of the following publications as references and technical aids:

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a. Manual of Cross-Connection Control, published by the Foundation for Cross-

Connection Control and Hydraulic Research, University of Southern California, or latest edition thereof.

b. Cross Connection Control Manual, Accepted Procedures and Practice, published by the

Pacific Northwest Section, American Water Works Association, or latest edition thereof.

c. Cross-Connection Control Guidance Manual for Small Water Systems, published by the

Washington State Department of Health, Office of Drinking Water.

4. The Purveyor shall incorporate the written program plan into the Water System Plan or

Small Water System Management Program as applicable and shall submit the program to

DOH for approval when requested.

C. Technical Provisions

1. The Purveyor’s CCS shall perform hazard assessments of all water system and water-using facilities owned by the Purveyor according to a reasonable schedule.

2. The Purveyor shall eliminate all cross-connections that are discovered by the CCS. Where it is impossible or impractical to eliminate the cross-connections, they shall be protected against by installation of a backflow preventer. The type, location and schedule of installation of the backflow preventer shall be as recommended by the Purveyor’s CCS.

3. When a facility or building owned or served by the Purveyor is of a type included on Table

9 of WAC 246-290-490(4), the building or facility plumbing system shall be isolated from the rest of the water system by installation of a reduced pressure principle backflow assembly (RPBA) or air gap (AG). The premises isolation backflow preventer will be installed at a location recommended by the CCS.

4. Cross-connection hazards found within buildings owned by the Purveyor will be protected against as according to the Uniform Plumbing Code (UPC) as amended for Washington. For cross-connection hazards and/or specific plumbing fixtures that are not address in the UPC, the Purveyor will provide protection in accordance with the fixture protection tables found in the most recently published edition of the PNWS-AWWA Cross-Connection Control

Manual.

5. All backflow preventers owned by the Purveyor shall be inspected and/or tested in accordance with WAC 246-290-490 (i.e. at the time of installation, after repair, reinstallation or relocation and after a backflow incident). After the initial test, the Purveyor will ensure that Purveyor-owned backflow preventers are tested at least once annually. The

Purveyor will ensure that a purveyor-approved, DOH-certified backflow assembly tester

(BAT) tests all assemblies. The Purveyor will reinstall, repair or replace as soon as feasible any backflow preventers that fail an inspection and/or a test.

6. The Purveyor shall maintain records of hazard assessments, backflow preventers, and backflow preventer tests and inspections. The Purveyor shall make all data concerning the

CCC program available to DOH when requested.

7. The Purveyor shall allocate resources as necessary to implement the provisions of this resolution and the CCC program adopted.

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D. Other Provisions

If any provisions in this resolution, or in the written CCC program plan adopted by the Purveyor, are found to be less stringent than or inconsistent with the Drinking Water Regulations (Chapter

246-290 WAC), the Uniform Plumbing Code (Chapter 51-56 WAC), or any other Washington State statutes or rules, the more stringent statute, rule, or regulations shall apply.

Resolution Passed: ________________________

Effective Date: ___________________________

Signatures: ______________________________

Appendix B.

Backflow Inspection and Testing Field Sheets

Backflow Preventer Inspection and Field Test Report

PWS ID Water System Name File # Facility Name ☐ Non-Residential ☐ Residential Service Address City Zip Contact Person Phone Email Hazard Type (if known) ☐ DCVA ☐ RPBA ☐ PVBA ☐ AG ☐Other Preventer Physical Location ☐ New ☐ Existing ☐ Replacement: Old Ser. # Confined Space Yes ☐ No ☐ Assembly Make Model Serial # Size ” USC-Approved Yes ☐ No ☐ Proper Install Yes ☐ No ☐ Proper Orientation Yes ☐ No ☐

Initial Test

Passed ☐

Failed ☐

DCVA RPBA PVBA/SVBA

Check Valve 1 Leaked ☐ psid

Check Valve 2 Leaked ☐ psid

Relief Valve Opened psid/ Not Open☐

Check Valve 2 Closed Tight ☐ Leaked ☐

Check Valve 1 psid

Approved Air Gap Yes☐ No☐

Air Inlet Valve Opened at psid Did Not Open ☐ Opened Fully Yes ☐ No☐

Check Valve psid Leaked ☐

Cleaning, Repairs, & Parts

Cleaned ☐ Repaired ☐ Cleaned ☐ Repaired ☐ Cleaned ☐ Repaired ☐

☐Disc ☐O-Ring(s) ☐Disc ☐O-Ring(s) ☐Air Inlet Disc ☐Float ☐Spring ☐Module ☐Spring ☐Module ☐Air Inlet Spring ☐Diaphragm ☐Guide ☐Rubber Kit ☐Diaphragm ☐Rubber Kit/Guide ☐Check Disc ☐Rubber Kit ☐Seat ☐ ☐Seat ☐ ☐Check Spring ☐

Final Test

Passed ☐

Failed ☐

Check Valve 1 Leaked ☐ psid Check Valve 2 Leaked ☐ psid

Relief Valve Opened at psid

Check Valve 2 Closed Tight ☐

Check Valve 1 psid

Air Inlet Valve Opened at psid Opened Fully Yes ☐ No☐ Check Valve psid

Air Gap Inspection Pass ☐ Fail ☐ Supply Pipe Diameter ” Air Gap Separation ” Line Pressure psi Detector Meter Gals☐ CuFt ☐ Service Restored Yes ☐ No☐ Remarks*

Test Kit Make & Model Serial # Ver./Cal Date** By this signature, I certify:

1. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB.

2. The information in this report is true, complete, and accurate.

BAT Signature (initial test) Cert. # Date/Time BAT Name (print) BAT Phone # Repaired By Date/Time BAT Signature (after repair) Cert. # Date/Time BAT Name (print) BAT Phone # BAT Company Name Address *Note unapproved backflow preventer, missing/defective components, repairs made, or conditions that may adversely affect assembly.

**The date of the most recent field test kit verification of accuracy or calibration whichever is most recent.

1. Backflow Preventer Inspection and Field Test Report

2. PWS ID 3. Water System Name 4. File #

5. Facility Name 6. ☐ Non-Residential ☐ Residential

7. Service Address City Zip

8. Contact Person 9. Phone 10. Email

11. Hazard Type (if known) 12. ☐ DCVA ☐ RPBA ☐ PVBA ☐ AG ☐Other

13. Preventer Physical Location

14. ☐ New ☐ Existing ☐ Replacement: Old Ser. # 15. Confined Space Yes ☐ No ☐

16. Assembly Make 17. Model 18. Serial # 19. Size ”

20. USC-Approved Yes☐ No ☐ 21. Proper Install Yes☐ No☐ 22. Proper Orientation Yes☐ No☐

23. Initial Test

Passed ☐

Failed ☐

DCVA RPBA PVBA/SVBA

Check Valve 1 Leaked ☐ psid

Check Valve 2 Leaked ☐ psid

Relief Valve Opened psid/ Not Open☐

Check Valve 2 Closed Tight ☐ Leaked ☐

Check Valve 1 psid

Approved Air Gap Yes☐ No☐

Air Inlet Valve Opened at psid Did Not Open ☐ Opened Fully Yes ☐ No☐

Check Valve psid Leaked ☐

24.

Cleaning, Repairs, & Parts

Cleaned ☐ Repaired ☐ Cleaned ☐ Repaired ☐ Cleaned ☐ Repaired ☐

☐Disc ☐O-Ring(s) ☐Disc ☐O-Ring(s) ☐Air Inlet Disc ☐Float ☐Spring ☐Module ☐Spring ☐Module ☐Air Inlet Spring ☐Diaphragm ☐Guide ☐Rubber Kit ☐Diaphragm ☐Rubber Kit/Guide ☐Check Disc ☐Rubber Kit ☐Seat ☐ ☐Seat ☐ ☐Check Spring ☐

25.

Final Test Passed ☐ Failed ☐

Check Valve 1 Leaked ☐ psid Check Valve 2 Leaked ☐ psid

Relief Valve Opened at psid

Check Valve 2 Closed Tight ☐

Check Valve 1 psid

Air Inlet Valve Opened at psid Opened Fully Yes ☐ No☐ Check Valve psid

26. Air Gap Inspection Pass ☐ Fail ☐ 27. Supply Pipe Diameter ” 28. Air Gap Separation ”

29. Line Pressure psi 30. Detector Meter Gals☐ CuFt ☐ 31. Service Restored Yes☐No☐

32. Remarks*

33. Test Kit Make & Model 34. Serial # 35. Ver./Cal Date**

36. By my signature, I certify:

1. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or

AVB.

2. The information in this report is true, complete, and accurate.

37. BAT Signature (initial test) 38. Cert. # 39. Date/Time

40. BAT Name (print) 41. BAT Phone #

42. Repaired By 43. Date/Time

44. BAT Signature (after repair) 45. Cert. # 46. Date/Time

47. BAT Name (print) 48. BAT Phone #

49. BAT Company Name 50. Address

*Note unapproved backflow preventer, missing/defective components, repairs made, or conditions that may adversely affect assembly.

**The date of the most recent field test kit verification of accuracy or calibration whichever is most recent.

Form Instructions

# Field Name Description Required Field?

WAC

246-292-036

1 Title Block May modify to identify the public water system requiring this test report, to identify the company performing the assembly inspection and field test or air gap inspection, or to display other information.

No

2 PWS ID The public water system identification number found on water system documents including the water facilities inventory (WFI). The Department of Health assigns this number to the water system.

No

3 Water System Name

Name of the public water system that serves the property where the backflow preventer being inspected/tested is installed.

No

4 File # Backflow prevention assembly or air gap tracking number assigned by the water system.

No

5 Facility Name Name of the business, institution, or resident where the backflow preventer is installed.

Yes (2)(a)

6 Non- Residential or Residential

Category that best describes the type of facility where the backflow preventer is installed.

No

7 Service Address

Street address, city, and ZIP code of the facility where the backflow preventer is installed.

Yes (2)(b)

8 Contact Person

Name of facility owner or owner’s representative. Yes (2)(c)

9 Phone Facility contact person’s phone number. Yes (2)(c)

10 Email Facility contact person’s email address. No

11 Hazard Type Description of the downstream hazard or premises, if known to the Backflow Assembly Tester (BAT). See Table 9 of WAC 246-290-490 for examples.

Yes (2)(d)

12 DCVA/RPBA/

PVBA/AG/

Other

Type of assembly inspected and tested.

DCVA = Double Check Valve Assembly, RPBA = Reduced Pressure Backflow Assembly, PVBA = Pressure Vacuum Breaker Assembly, AG = Air Gap. If “Other”, describe type, such as DCDA or RPDA

Yes (3)(b)

13 Preventer Physical Location

Detailed description of the backflow preventer’s location within or outside facility (ex., at the meter or at the SW corner of mechanical room).

Yes (3)(a)

14 New, Existing, Replacement

Indicate if the assembly is a new install, an existing assembly, or a replacement assembly. For replacement assemblies, provide the serial number of the assembly being replaced.

Yes (3)(h) and (3)(i)

15 Confined Space

Optional data entry field requested by some water systems to indicate if the assembly is located in a confined space.

No

16 Assembly Make

Enter the make (manufacturer’s name) of the assembly being tested. This information will either be cast or stamped on the assembly body or appear on the assembly’s nameplate.

Yes (3)(c)

7/24/15 Draft

WAC

246-292-036

17 Model Enter the model (name; number) of the assembly being tested. This information will either be cast or stamped on the assembly body or appear on the assembly’s nameplate.

Yes (3)(d)

18 Serial # Enter the serial number of the assembly being tested. This information will either be cast or stamped on the body or appear on the assembly’s nameplate.

Yes (3)(e)

19 Size Enter the size (in inches) of the assembly being tested. This information will either be cast or stamped on the assembly body or appear on the assembly’s nameplate.

Yes (3)(f)

20 USC-Approved Indicate if the assembly being tested appears on the USC List of Approved Backflow Prevention Assemblies. The make, model, and size must exactly match the information on the USC List to be “USC-approved”.

Access the USC List at:

http://www.usc.edu/dept/fccchr/list.html or http://www.usclist.com/ (Mobile Version)

Yes (3)(g)

21 Proper Install Indicate if the assembly is properly installed according to industry standards. If not properly installed, explain in comments.

Yes (4)(b)

22 Proper Orientation

Indicate if the assembly is installed in an approved orientation as shown on the USC List of Approved Backflow Prevention Assemblies for the specific make, model, and size of assembly. If not installed in an approved orientation, explain in comments.

Yes (4)(a)

23 Initial Test Passed/Failed

Evaluate assembly for a pass or fail condition based on accurate field test kit readings recorded when conducting the initial test per USC 10th Edition field test procedures. Enter the field test result for the initial test.

Yes (5)

24 Cleaning, Repairs, & Parts

Check applicable box (or boxes) to describe maintenance performed, repairs made, and parts replaced.

Yes (6)

25 Final Test Passed/Failed

Evaluate assembly for a pass or fail condition based on accurate field test kit readings recorded when conducting the final test per USC 10th Edition field test procedures. Enter the field test result for the final test.

Yes (5)

26 Air Gap Inspection Passed/Failed

After measuring the supply pipe diameter and air gap separation, indicate if the air gap met the definition of an approved air gap (see WAC 246-290-010) at the time of inspection.

Yes (4)(c) and (8)(c)

27 Air Gap Supply Pipe Diameter

Enter the diameter, in inches, of the pipe supplying water to the air gap.

Yes (8)(a)

28 Air Gap Separation

Enter the length, in inches, of the air gap, i.e., the physical separation between the free-flowing discharge end of the supply pipe and the overflow rim of the open or non-pressure receiving vessel.

Yes (8)(b)

7/24/15 Draft

Form Instructions http://www.usc.edu/dept/fccchr/list.html http://www.usclist.com/

WAC

246-292-036

29 Line Pressure Optional data entry field requested by some water systems to indicate water system pressure (in pounds per square inch) at the inlet of the backflow prevention assembly to be tested.

No

30 Detector Assembly Meter Reading

Optional data entry field requested by some water systems to detect unauthorized water use. Enter the number displayed on the flow meter installed on the detector assembly. Indicate units (i.e., gallons or cubic feet).

No

31 Service Restored

Optional data entry field requested by some water systems to indicate if, after field-testing the assembly, the BAT restored water service to the original condition.

No

32 Remarks Use this section to provide additional information to the water purveyor and assembly owner. Indicate if the assembly is not USC-approved, list missing or defective components, describe any conditions that could adversely affect assembly performance, or report any other unusual or special circumstances or observations.

Yes (9)

33 Test Kit Make & Model

Enter the make (manufacturer) and model of the field test kit the BAT used to test the assembly.

Yes (7)(a) and (7)(b)

34 Test Kit Serial

Enter the serial number of the field test kit the BAT used to test the assembly.

Yes (7)(c)

35 Ver./Cal Date Enter the date of the most recent field test kit verification of accuracy or calibration, whichever is more recent.

Yes (7)(d)

36 Certification Statement

By signing the test report, the BAT certifies that he/she personally inspected and field tested the backflow assembly, preventer or inspected the air gap or AVB, used USC 10th Edition field test procedures, a field test kit complying with the WAC 246-292-034, and provided true, complete, and accurate information on the field test report.

Yes (12)

37 BAT Signature (initial test)

Enter the signature of the certified BAT that performed the initial field test.

Yes (13)

38 Cert. # Enter the Department of Health issued BAT certification number for the BAT that performed the initial inspection and field test.

Yes (10)(d)

39 Date Enter the date the BAT conducted the initial backflow assembly inspection and field test, air gap or AVB inspection.

Yes (11)

39 Time Optional data entry field requested by some water systems.

Enter the time the BAT conducted the initial backflow assembly inspection and field test, air gap or AVB inspection.

No

40 BAT Name (Print)

Print the name of the certified BAT who performed the initial inspection and field test.

Yes (10)(a)

41 BAT Phone # Enter the phone number of the certified BAT who performed the initial inspection and field test.

Yes (10)(c)

42 Repaired By Enter the name of the person that repaired the backflow assembly.

Yes (10)(a)

43 Date Enter the date the BAT performed the backflow assembly maintenance or repair (or re-plumbed the air gap).

Yes (11)

WAC

246-292-036

43 Time Optional data entry field requested by some water systems.

Enter the time the BAT performed the assembly maintenance or repair (or re-plumbed the air gap).

No

44 BAT Signature Enter the signature of the certified BAT that performed the final field test after repairs.

Yes (13)

45 Cert. # Enter the BAT certification number for the BAT who performed the final field test after repairs. This number is issued by the Department of Health.

Yes (10)(d)

46 Date Enter the date the certified BAT conducted the final field test after repairs.

Yes (11)

46 Time Enter the time the certified BAT conducted the final field test after repairs.

No

47 BAT Name (Print)

Print the name of the certified BAT who performed the final field test after repairs.

Yes (10)(a)

48 BAT Phone # Enter the phone number of the certified BAT who performed the final field test after repairs.

Yes (10)(c)

49 BAT Company Name

Enter the name of the company owned by the certified BAT or that employed the BAT conducting the assembly inspection and field test or air gap inspection.

Yes (10)(b)

50 Address Enter the address of the company listed in field #47. No

Please provide any comments, questions, or suggestions to CCCprogram@DOH.WA.GOV mailto:CCCprogram@DOH.WA.GOV

Appendix C1.

Example Materials

Drinking water systems may become

Polluted or

Contaminated through uncontrolled cross connections

What is a Cross Connection?

A cross connection is a point in a plumbing system where the potable water supply is con-nected to a non-potable source. Briefly, a cross connection exists whenever the drinking water system is or could be connected to any non-potable source (plumbing fixture, equipment used in any plumbing system). Pollutants or contami-nants can enter the safe drinking water system through uncontrolled cross connections when backflow occurs.

Backflow is the unwanted flow of non-potable substances back into the consumer’s plumbing system and/or public water system (i.e., drinking water).

There are two types of backflow: backsiphonage and backpressure. Backsiphonage is caused by a negative pressure in the supply line to a facility or plumbing fixture. Backsiphonage may occur during waterline breaks, when repairs are made to the waterlines, when shutting off the water supply, etc.

Backpressure can occur when the potable water supply is connected to another system operated at a higher pressure or has the ability to create pressure. Principal causes are booster pumps, pressure vessels and elevated plumbing.

Backflow preventers are mechanical devices designed to prevent backflow through cross connections. However, for backflow preventers to protect as designed, they must meet stringent installation requirements.

Cross Connections can create

Health Hazards

© 2003 R 06/03 [Brochure #2]

American Water Works Association Pacific Northwest Section

For further information contact your local water purveyor or the

PNWS/AWWA

Cross-Connection

Control Committee through the

PNWS office at

(877) 767-2992 or on the web at www.pnws-awwa.org

Page 1 of 2Appendix C1. Example Materials

BOILER

POTABLE

WATER

NON-POTABLE

WATER

BOILER

POTABLE

WATER

NON-POTABLE

WATER

BACKFLOW PREVENTER

Why Be Concerned?

Most water systems in the United States and Canada have good sources of water and/or sophisticated treatment plants to convert impure water to meet drinking water standards. Millions of dollars are spent to make the water potable before it enters the distribution system so most water purveyors think that their supplies are not in jeopardy from this point

on. Studies have proven this to be wrong. Drinking water systems may become polluted or contami-nated in the distribution system through uncon-trolled cross connections.

Cross connections are installed each day in the United States because people are unaware of the problems they can create. Death, illness, contami-nated food products, industrial and chemical products rendered useless are some of the conse-quences of such connections. As a result, many hours and dollars are lost due to cross connections.

Where are Cross Connections Found?

Cross connections are found in all plumbing systems. It is important that each cross connection be identified and evaluated as to the type of backflow protection required to protect the drinking water supply. Some plumbing fixtures have built-in backflow protection in the form of a physical air gap. However, most cross connections will need to be controlled through the installation of an approved mechanical backflow prevention device or assembly. Some common cross connections found in plumbing and water systems include:

1. Wash basins and service sinks.

2. Hose bibs.

3. Irrigation sprinkler systems.

4. Auxiliary water supplies.

5. Laboratory and aspirator equipment.

6. Photo developing equipment.

7. Processing tanks.

8. Boilers.

9. Water recirculating systems.

10. Swimming pools.

11. Solar heat systems.

12. Fire sprinkler systems.

Every water system has cross connections. Plumbing codes and State drinking water regulations require cross connec-tions to be controlled by approved methods (physical air gap) or approved mechanical backflow prevention devices or assemblies. The various types of mechanical backflow preventers include: reduced pressure backflow assembly (RPBA), reduced pressure detector assembly (RPDA), double check valve assembly (DCVA), double check detector assembly (DCDA), pressure vacuum breaker assembly (PVBA), spill resistant vacuum breaker assembly (SVBA) and atmospheric vacuum breaker (AVB).

For a backflow preventer to provide proper protection, it must be approved for backflow protection, designed for the degree of hazard and backflow it is controlling, installed correctly, tested annually by a State certified tester, and repaired as necessary. Some states require mandatory backflow protection on certain facilities where high health-hazard-type cross connections are normally found. The following is a partial list of those facilities:

1. Hospitals, mortuaries, clinics.

2. Laboratories.

3. Food and beverage processing centers.

4. Metal plating and chemical plants.

5. Car washes.

6. Petroleum processing and storage plants.

7. Piers and docks.

8. Sewage treatment plants.

Wrong:

Uncontrolled Cross Connection

Right:

Controlled Cross Connection

What to Do?

It is impossible to cover all of the information pertaining to cross connections in a pamphlet.

We hope the preceding information will inspire you to further educate yourself on the hazards of unprotected cross connections. Cross connection control manuals and training schools are offered throughout the Northwest.

Information on manuals, schools and cross connection control can be obtained from:

Washington Department of Health Airdustrial Way, Bldg. 3 P.O. Box 47822 Olympia WA 98504-7822

(360) 236-3133

Oregon Oregon Health Division 3420 Cherry Av NE, #110 Keizer OR 97303

(503) 373-7201

British Columbia, Canada BC Water & Waste Association Ste. 342 – 17 Fawcett Road Coquitlam B.C. V3K 6V2

(604) 540-0111

Idaho Idaho Division of Environment 1410 N Hilton Boise ID 83706

(208) 373-0275

Additional sources of information may be found on the PNWS-AWWA web site:

www.pnws-awwa.org

Page 2 of 2Appendix C1. Example Materials

Appendix C2.

Cross-Connection Education Records

Appendix C2. Cross-Connection Education Records

Brochure Class

Name/ID X Month/Date/Year

Method Employee Date Provided

Mann-Grandstaff VAMC | Control Plan

September 2018

CES - Spokane Valley, WA

Doc: App C2. Education Documentation.xlsx | Implementation Records

Appendix D1.

Cross-Connection Activities Report

Public Water System

Cross-Connection Control Activities

Annual Summary Report for ____

CCC Activities Report (Blue) 1 DOH Form 331-155 (Rev 01/29/18)

Part 1: Public Water System (PWS) and Cross-Connection Control Specialist (CCS) Information

PWS ID: PWS Name: County:

Provide name and certification number of CCS who develops and implements your CCC program.

CCS Name (Last, First & MI): CCS Phone: (___) ___-____ CCS Cert. No.: BAT Cert. No. (if applicable):

CCS is (check one): PWS owner or employee On contract to PWS Volunteer or other

Part 2: Status of Cross-Connection Control (CCC) Program at end of Reporting Year

PWS has (check one box in each column below):

A written CCC program plan Y N CCC implementation activities Y N

(CCC program plan may be a separate document or part of water system plan or small water system management program.)

Provide information about PWS’s specific CCC Program Elements. Check one box in each column for each row.

Program

Element

Number

Description of Element

[See WAC 246-290-490(3)]

This Program Element is Currently:

Included in

Written Program

Being Implemented or is Completed

1 Legal Authority Established Y N Y N

2 Hazard Evaluation Procedures and Schedules Y N Y N

3 CCC Procedures and Schedules Y N Y N

4…