Form 7 "Cross-connection Survey Report Form & Violation Notice" - Massachusetts

What Is Form 7?

This is a legal form that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 5, 2012;
  • The latest edition provided by the Massachusetts Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 7 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Download Form 7 "Cross-connection Survey Report Form & Violation Notice" - Massachusetts

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Cross-Connection Survey Report Form & Violation Notice
(Print Clearly)
Date of CC Survey _______/_______/_______
PWS ID#
____/____/____/____/____/____/____
PWS Name ___________________________________________
City/Town ________________________________
Facility Information
1. Facility Name (Business, Co., Corp.):__________________________________________________________________
2. Facility Address:_____________________________________________________________, MA _________________
3. Mailing Address:___________________________________________________________________________________
4. Contact Person:___________________________________________
Phone # (______)_______-_____________
5. Type of facility:
Industrial
Commercial
Institutional
Municipal
Other_____________________________________
6. Describe the facility use(i.e. motel, school):______________________________________________________________
7. Size of service connection:_________ inch.
Is service connection metered?
YES
NO
8. Is there a supplemental protection at meter required (containment device)?
YES
NO
If YES, what type of backflow device is in use?
Reduce Pressure Backflow Preventer (RPBP)
Double Check Valve Assembly (DCVA)
9. Does this facility require non-interrupted water service?
YES
NO
10. Does boiler feed utilize chemical additives?
YES
NO
If YES, is the boiler protected with a backflow device?
YES
NO
11. Does this facility have an air conditioning cooling tower?
YES
NO
If YES, is the cooling tower protected with a backflow device?
YES
NO
12. Is a water saver in use on condensing lines or cooling tower?
YES
NO
If YES, is the make-up supply line protected with a backflow device?
YES
NO
13. Is process water in use in this facility?
YES
NO
If YES, is the process water “potable” water or “raw” water?
Potable
Raw
Is the process water lines protected with a backflow device?
YES
NO
14. Does this facility have a fire protection system?
YES
NO
If YES, is the fire protection system supplied by a dedicated water line?
YES
NO
What type of backflow device is being used on the fire protection system?
Single swing check valve (SSCV)
Reduce Pressure Backflow Preventer (RPBP)
Double Check Valve Assembly (DCVA)
Other________________________________________
15. Contamination:
Biological (type) ________________________
Chemical Compound _______________________
Other (describe) ___________________________________________________________________
Violation(s) Found
NO violation(s) was/were found at the time of this cross-connection survey was conducted.
Degree of Hazard
Exact Location of Cross-connection
Comments
High
Low
High
Low
High
Low
High
Low
I certified that the above cross-connection survey findings are true. (Signatures required)
 Cross-connection Survey Conducted by a MassDEP Certified Cross-connection Surveyor
___________________________ ______________ ____/____/____ ________________________ (_____)_____-
_________
CC Surveyor Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
 Cross-connection Survey Witnessed by: (Facility Owner/Representative)
___________________________________
________________________ _______________________ ____/____/____
Facility Owner/Representative Name (Print)
Title
Signature
Note:  Use the attached table for protection options.
 Provide to the facility owner/representative a copy of this form.
Cross-Connection Survey Report Form & Violation Notice
(Print Clearly)
Date of CC Survey _______/_______/_______
PWS ID#
____/____/____/____/____/____/____
PWS Name ___________________________________________
City/Town ________________________________
Facility Information
1. Facility Name (Business, Co., Corp.):__________________________________________________________________
2. Facility Address:_____________________________________________________________, MA _________________
3. Mailing Address:___________________________________________________________________________________
4. Contact Person:___________________________________________
Phone # (______)_______-_____________
5. Type of facility:
Industrial
Commercial
Institutional
Municipal
Other_____________________________________
6. Describe the facility use(i.e. motel, school):______________________________________________________________
7. Size of service connection:_________ inch.
Is service connection metered?
YES
NO
8. Is there a supplemental protection at meter required (containment device)?
YES
NO
If YES, what type of backflow device is in use?
Reduce Pressure Backflow Preventer (RPBP)
Double Check Valve Assembly (DCVA)
9. Does this facility require non-interrupted water service?
YES
NO
10. Does boiler feed utilize chemical additives?
YES
NO
If YES, is the boiler protected with a backflow device?
YES
NO
11. Does this facility have an air conditioning cooling tower?
YES
NO
If YES, is the cooling tower protected with a backflow device?
YES
NO
12. Is a water saver in use on condensing lines or cooling tower?
YES
NO
If YES, is the make-up supply line protected with a backflow device?
YES
NO
13. Is process water in use in this facility?
YES
NO
If YES, is the process water “potable” water or “raw” water?
Potable
Raw
Is the process water lines protected with a backflow device?
YES
NO
14. Does this facility have a fire protection system?
YES
NO
If YES, is the fire protection system supplied by a dedicated water line?
YES
NO
What type of backflow device is being used on the fire protection system?
Single swing check valve (SSCV)
Reduce Pressure Backflow Preventer (RPBP)
Double Check Valve Assembly (DCVA)
Other________________________________________
15. Contamination:
Biological (type) ________________________
Chemical Compound _______________________
Other (describe) ___________________________________________________________________
Violation(s) Found
NO violation(s) was/were found at the time of this cross-connection survey was conducted.
Degree of Hazard
Exact Location of Cross-connection
Comments
High
Low
High
Low
High
Low
High
Low
I certified that the above cross-connection survey findings are true. (Signatures required)
 Cross-connection Survey Conducted by a MassDEP Certified Cross-connection Surveyor
___________________________ ______________ ____/____/____ ________________________ (_____)_____-
_________
CC Surveyor Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
 Cross-connection Survey Witnessed by: (Facility Owner/Representative)
___________________________________
________________________ _______________________ ____/____/____
Facility Owner/Representative Name (Print)
Title
Signature
Note:  Use the attached table for protection options.
 Provide to the facility owner/representative a copy of this form.
P:/OPS/XCONN/CC Survey Report Form #7 (Revised 07/05/2012)
TABLE 22-1
Types of Backflow Prevention Devices Required: Subject to the provisions of 310 CMR 22.22(10), Table 310 CMR 22-1 shall
serve as the guide for the type of protection required.
AG
- Air Gap
AVB
- Atmospheric Vacuum Breaker
RPBP - Reduced Pressure Backflow Preventer
PVB
- Pressure Vacuum Breaker
DCVA - Double Check Valve Assembly
BPIAV - Backflow Preventer with Intermediate
Atmospheric Vent
Acceptable Types of Backflow
Preventers
Types of Hazard on Premises
AG RPBP DCVA AVB PVB BPIAV
Comments*
1. Sewage Treatment Plant
X
X
2. Sewage Pumping Station
X
X
3. Food Processing
X
X
X*
* If no health hazard exists
4. Laboratories
X
X
X*
* If no health hazard exists
5. Fixtures with hose threads on inlets
X
X
X
X
In addition to an air gap separation, all fixtures
that have a threaded hose type connection shall at
a minimum, be equipped with a AVB in
accordance with 248 CMR 2.14
6. Hospitals, Mortuaries, Clinics
X
X
7. Plating Facilities
X
X
8. Irrigation Systems
X
X
X*
X**
Each case should be evaluated individually.
* An AVB can be used if no back pressure is
possible and no health hazard exists.
** Pressure Vacuum Breakers can be installed if
back pressure is not possible
9. Systems or Equipment Using Radioactive
X
X
Material
10. Submerged Inlets
X
X
X*
* If no health hazard exists and no back pressure
is possible
11. Dockside Facilities
X
X
12. Valved outlets or fixtures with hose
X
X
X*
Each case should be evaluated individually
* If no health hazard exists and no back pressure
attachments
is possible
13. Commercial Laundries and Dry Cleaners
X
X
14. Commercial Dishwashing Machines
X
X
X*
* If no health hazard exists
15. High and Low Pressure Boilers
X
X*
* If chemicals are added
16. Low Pressure Heating Boilers
X
Residential and small commercial, having no
chemicals added
17. Photo Processing Equipment
X
X
18. Reservoirs – Cooling Tower Re-circulating
X
X
Systems
19. Fire Protection Systems:
For cross connection control, fire protection systems may be classified on the basis of water source and arrangement of supplies as follows:
19. Fire Protection Systems (continued)
A backflow prevention assembly does not have to
19.a. Class 1: Direct connection from public water
be installed on existing fire protection systems
X
X
X
system mains only; no pumps, tanks, or reservoirs; no
installed prior to March 21, 1997, provided that
physical connection from other water supplies; no
the fire protection system is registered with the
antifreeze or other additives of any kind; all sprinkler
public water system, equipped with a UL listed
drains discharge to atmosphere, dry wells, or other
alarm check valve that is properly maintained in
safe outlets. These systems may or may not have fire
accordance with NFPA 25 and has not undergone
department
connections.
Refer
to
310
CMR
substantial modification defined within 310 CMR
22.22(9)(d)1.
22.22(9)(d)3. Alarm check maintenance records
must
be
available
for
inspection
by
the
Department, its designee or the public water
system
19.b. Class 2: Same as Class 1 except that booster
X
X
X
A backflow prevention assembly does not have to
pumps may be installed in the connections from the
be installed on existing fire protection system
street mains .These systems may or may not have fire
installed prior to March 21, 1997, provided that
department
connections.
Refer
to
310
CMR
the fire protection system is registered with the
22.22(9)(a).
public water system and equipped with a UL
listed alarm check valve that is properly
maintained in accordance with NFPA 25. Alarm
check maintenance records must be available for
inspection by the Department, its designee or the
public water system
19.c. Class 3: Direct connection from public water
X
X*
X*
* RPBP or DCVA contingent on evaluation of
system mains, plus one or more of the following:
auxiliary supply and on-site system in accordance
elevated storage tanks; fire pumps taking suction from
with 310 CMR 22.22(9)(d)1.
aboveground covered reservoirs, or tanks; and
pressure tanks.
19.d. Class 4: Directly supplied from public water
* RPBP on evaluation of auxiliary supply and on-
system mains, similar to Class 1 and Class 2 with an
site system in accordance with 310 CMR
X
X*
auxiliary water supply dedicated to fire department
22.22(9)(d)1.
use and available to the premises, such as an non-
potable water source located within 1700 feet of the
fire department connection, (FDC).
19.e. Class 5: Directly supplied from public water
X*
X*
* RPBP or air gap contingent on evaluation of
system mains, and interconnected with auxiliary
auxiliary supply and on-site system. Refer to 310
supplies, such as pumps taking suction from
CMR 22.22(9)(d)1.
reservoirs exposed to contamination, or rivers and
ponds; driven wells; mills or other industrial water
systems; or where antifreeze or other additives are
used.
19.f. Class 6: Combined industrial and fire protection
X
X*
X
X
* RPBP contingent on evaluation of on-site water
systems supplied from the public water mains only,
system Refer to 310 CMR22.22 (9)(d)1.
with or without gravity storage or pump suction tanks.
19.g. Residential fire protection systems for one and
X
X
X
Non testable devices and flow through systems
two family detached dwellings and manufactured
should be used whenever possible. Systems are
homes only. Fire protection systems in three family
typically designed and installed in accordance
dwellings meeting NFPA 13D requirements as
with NFPA 13D: "Installation of Sprinkler
provided in 780 CMR, Chapter 9, are included in this
systems in One and Two Family Dwellings and
section.
manufactured
homes."
These
systems
are
authorized to use food grade antifreeze with no
additional requirements when potable piping (PB,
CPVC, and copper tube) is employed. If non-
grade antifreeze is utilized, the system may be
classified as a class 5. If a fire department
connection is used, the requirements for a class 1
or 2 apply.
19.h. Residential fire protection systems for other
X
X
X
Fire protection system in this category shall
than those described in Table 22-1-19.g.
comply with the requirements set forth in class 1
through 4 as appropriate.
20. Solar Energy Systems
X
X
X*
Residential and small commercial having no
chemicals or only USP Glycenne added to water
21. Single Jacketed Heat Exchangers
X
X
Each case should evaluated individually
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