Backflow Prevention
Publications
Forms
Permission for use from the University
of Southern California does not allow web posting of the
documents below. Limited distribution of hard copies is allowed
only to regulated entities and consultants working in Washington
State. However, you can order the publications through our
on-line catalog links below.
Backflow Incident Report Form
#331-243 (188 KB Word) - Cross-Connection Control
Program
Has your water system ever had a backflow incident?
Backflow is when
water flows in the opposite direction than intended. Under
backflow conditions, contaminants may enter the drinking water
supply through unprotected cross-connections. Sometimes
the contaminant is confined to the customer's plumbing system.
Other times the contaminant may enter the distribution system.
Washington State
Drinking Water rules [WAC 246-290-490(8)] require water
purveyors to document details of backflow incidents using the
above form.
To complete the
backflow incident form, you can either:
- Fill out the form on your computer
in Word, and then print it for your signature (preferred
method).
- Print out the form and complete it
manually.
Please send the
signed, completed form to:
Washington State
Department of Health
Office of Drinking Water - CCC Program Manager
P O Box 47822
Olympia, WA 98504-7822
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