Five Elements - For Cross Connection Control Program

1. Local Authority

2. Public Education and Awareness

  • Tracking Form - Template
  • WATTS Informative Packet
  • Thermal Expansion Education - Template
  • CCC Protect Your Drinking Water Supply -flyer
  • CCR (Consumer Confidence Report). If your annual CCR has Cross Connection Control language in it, highlight it and put it in this section. (Get help from RWAU to complete your CCR by calling RWAU at 801-765-5123)
  • Anything that you have done or used for Public Education & Awareness (handouts, website information, postings. etc) should go in this section

3. Trained/Certified Staff

  • ‚ÄčTrained/Certified Staff Tracking Form - Template 
  • Certificates (you should also include a copy of any Cross Connection 101, Backflow Tester/Technician, and/or Cross Connection Administrator certification in this section)
  • Visit our RWAU Training page to see when the next Cross Connection classes are being held

4. Written Records

5. On-going Enforcement

  • Enforcement Tracking Form - Template
  • Hazard Assessment Survey Form - Template
  • Hazard Assessment Notices & Test Notice Letters:
  • Test Reports/Forms: These forms are usually available at the local city or town building department office in a triplicate form type. This way the backflow technician who tested the backflow assembly can provide the water customer and the city or town office a copy, as well as keep a copy for her/his records. to see what they look like, you can view an example on the last page of the Cross Connection Control Program of Utah. Remember that the Backflow Tester is required to provide the water system with a copy as well as the customer.
  • Residential Survey Questionnaire - Template (This questionnaire can also give you ideas for Public Education and what to look for during Hazard Assessments)
  • List of Certified Backflow Assembly Testers that can be sorted via city or name. (You may get a list from the DDW's Backflow webpage.)

Do you have Cross Connection Control IPS Deficiencies from your State conducted Sanitary Survey?

check for ips deficiencies

Submit your Cross Connection Control Program to the Utah Division of Drinking Water:

Division of Drinking Water's Cross Connection Webpage - Gary Rager/DDW

It's important to know if your water system as Cross Connection Control Program Deficiency Points on your IPS -

Deficiency Reporting (Sanitary Survey)

Adobe Reader Users Fill out the form, select the “Submit by Email” button, and Email the xml file to (using the Wizard to create the xml file). Note: If you are using the Chrome browser, the Adobe Reader plug-in won’t work. Use Internet Explorer or open the PDF in Adobe Reader directly. Adobe Pro Users Fill out the form, save the PDF, then Email the PDF file to

See also Sanitary Survey.

Contact us at with questions.