"Cross-connection Control Program Plan Questionnaire for Non-community Public Water Systems (Transient & Non-transient - Tnc & Ntnc)" - Massachusetts

Cross-connection Control Program Plan Questionnaire for Non-community Public Water Systems (Transient & Non-transient - Tnc & Ntnc) is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on September 23, 2021;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

ADVERTISEMENT
ADVERTISEMENT

Download "Cross-connection Control Program Plan Questionnaire for Non-community Public Water Systems (Transient & Non-transient - Tnc & Ntnc)" - Massachusetts

Download PDF

Fill PDF online

Rate (4.7 / 5) 24 votes
Charles D. Baker
Kathleen A. Theoharides
Governor
Secretary
Karyn E. Polito
Martin Suuberg
Lieutenant Governor
Commissioner
CROSS-CONNECTION CONTROL PROGRAM PLAN QUESTIONNAIRE
FOR NON-COMMUNITY PUBLIC WATER SYSTEMS
(TRANSIENT & NON-TRANSIENT – TNC & NTNC)
I. PUBLIC WATER SYSTEM RESPONSIBILITIES
Pursuant to 310 CMR 22.22 Cross Connections Distribution System Protection, every public water system shall:
1) Be responsible for the quality of water delivered to its consumers to the last free flowing outlet and for the safety of the
public water system under its jurisdiction; and
2) Have a Cross-connection Control Program (CCCP) plan that is approved by the Massachusetts Department of
Environmental Protection (MassDEP).
Our records indicate that your public water system does not have a Cross-connection Control Program plan approved by
MassDEP. This document once completed for your public water system and approved by MassDEP, may become your
Cross-connection Control Program Plan. Please take the time to answer all the questions to the best of your ability.
Your public water system will be in noncompliance of 310 CMR 22.22 if you fail to submit to MassDEP for its approval
of your Cross-connection Control Program plan. Your public water system may also be subject to enforcement,
including, but not limited to the assessment of civil administrative penalties by MassDEP. A civil administrative penalty
may be assessed by MassDEP for every day that the public water system is in noncompliance with its Cross-
connection Control Program responsibilities.
PUBLIC WATER SYSTEM INFORMATION
II.
(Print)
PWS ID#:
____/____/____/____/____/____/____
City/Town _______________________________
PWS Name:
____________________________________________________________________________
Class:
Non-Transient Non-Community (NTNC)
Transient Non-Community (TNC)
Type of use:
Industrial
Commercial
Institutional
Water Vending Machine
Other ____________________________________________
Facility Address __________________________________
_____________________ MA ___________
Street
City
State Zip
Mailing Address __________________________________ _____________________ ___ ___________
Street
City
State Zip
PWS Official:
Ms.
Mr. ___________________________________
(_____)_______-__________
Name (Print)
PWS Official E-mail Address: ________________________________________________________________
Certified Operator:
Ms.
Mr. _______________________________ (______)______-__________
Name
Grade(s):
Certificate ID#: _____________
This information is available in alternate format. Call the MassDEP Diversity Office at 617-556-1139. TTY# MassRelay Service 1-800-439-2370
MassDEP Website: www.mass.gov/dep
Printed on Recycled Paper
Charles D. Baker
Kathleen A. Theoharides
Governor
Secretary
Karyn E. Polito
Martin Suuberg
Lieutenant Governor
Commissioner
CROSS-CONNECTION CONTROL PROGRAM PLAN QUESTIONNAIRE
FOR NON-COMMUNITY PUBLIC WATER SYSTEMS
(TRANSIENT & NON-TRANSIENT – TNC & NTNC)
I. PUBLIC WATER SYSTEM RESPONSIBILITIES
Pursuant to 310 CMR 22.22 Cross Connections Distribution System Protection, every public water system shall:
1) Be responsible for the quality of water delivered to its consumers to the last free flowing outlet and for the safety of the
public water system under its jurisdiction; and
2) Have a Cross-connection Control Program (CCCP) plan that is approved by the Massachusetts Department of
Environmental Protection (MassDEP).
Our records indicate that your public water system does not have a Cross-connection Control Program plan approved by
MassDEP. This document once completed for your public water system and approved by MassDEP, may become your
Cross-connection Control Program Plan. Please take the time to answer all the questions to the best of your ability.
Your public water system will be in noncompliance of 310 CMR 22.22 if you fail to submit to MassDEP for its approval
of your Cross-connection Control Program plan. Your public water system may also be subject to enforcement,
including, but not limited to the assessment of civil administrative penalties by MassDEP. A civil administrative penalty
may be assessed by MassDEP for every day that the public water system is in noncompliance with its Cross-
connection Control Program responsibilities.
PUBLIC WATER SYSTEM INFORMATION
II.
(Print)
PWS ID#:
____/____/____/____/____/____/____
City/Town _______________________________
PWS Name:
____________________________________________________________________________
Class:
Non-Transient Non-Community (NTNC)
Transient Non-Community (TNC)
Type of use:
Industrial
Commercial
Institutional
Water Vending Machine
Other ____________________________________________
Facility Address __________________________________
_____________________ MA ___________
Street
City
State Zip
Mailing Address __________________________________ _____________________ ___ ___________
Street
City
State Zip
PWS Official:
Ms.
Mr. ___________________________________
(_____)_______-__________
Name (Print)
PWS Official E-mail Address: ________________________________________________________________
Certified Operator:
Ms.
Mr. _______________________________ (______)______-__________
Name
Grade(s):
Certificate ID#: _____________
This information is available in alternate format. Call the MassDEP Diversity Office at 617-556-1139. TTY# MassRelay Service 1-800-439-2370
MassDEP Website: www.mass.gov/dep
Printed on Recycled Paper
III. CCCP PLAN QUESTIONNAIRE
1. Has your public water system ever been surveyed for cross-connection?
A cross-connection survey is the inspection of the drinking water lines to identify cross-connections. A cross-
connection is a connection between a drinking water pipe and any equipment or pipe carrying non-potable
liquids (i.e. chemicals, waste water) or gases. Cross-connection can be found in the following locations:
boilers, lawn irrigation system, swimming pool, fire protection system, dishwasher, central air conditioning or
cooling systems, outside watering taps and garden hoses, etc. The Massachusetts Cross-connection
Control Program, 310 CMR 22.22(3)(c), requires that all non-residential facilities shall be surveyed for cross-
YES
NO
connections and all cross-connections found must eliminated or properly protected by an appropriate
Please note: all cross-connection surveys must be
backflow preventer device or assembly.
conducted by a MassDEP Certified Cross-connection Surveyor.
If NO, go to question #3
2. Was the cross-connection survey conducted by a Massachusetts Certified Cross-
connection Surveyor?
If YES, provide date of the survey was conducted, name of surveyor(s), certification number and
certification expiration date. (If more than one, use additional sheet.)
YES
NO
Attached a copy of the cc survey conducted to this questionnaire.
____/____/____
____________________________
_____________
_____/_____/_____
Date of Survey
Surveyor’s Name (Print)
MassDEP Cert. ID#
Cert. Expiration Date
3. If the answer to question #1 was NO, your public water system must have a cross-
connection survey conduct immediately. Effective January 1, 1999, a Massachusetts Certified
Cross-connection Surveyor shall conduct all cross-connection surveys.
Please, provide the information of the Massachusetts certified cross-connection surveyor that
YES
NO
conducted the survey.
____________________________________
_________________
_____/_____/_____
Name (Print)
MassDEP Certification ID#
Expiration Date
4. Have you taken the appropriate actions to eliminate or properly protect all cross-
connections found?
If YES, list the type of backflow prevention devices or assemblies used: (check all that apply)
AVB
PVB
DCVA
RPBP
Other ________________________________
YES
NO
AVB = atmospheric vacuum breaker
PVB = pressure vacuum breaker
DCVA = double check valve assembly
RPBP = reduced pressure backflow preventer
If NO, your system is vulnerable in the event of a backflow caused by backsiphonage or
backpressure
5. Were the backflow prevention devices and assemblies tested in accordance with the
frequency stated in 310 CMR 22.22(14)(d): RPBP: semi-annually and DCVA: annually?
YES
NO
A Massachusetts Certified Backflow Prevention Device Tester shall test all backflow prevention
devices.
6. Do you ensure or plan to ensure that backflow prevention devices are installed according
to the approved design data sheet and plans, and tested for proper operation upon
YES
NO
completion of the installation? A Massachusetts Certified Backflow Prevention Device Tester
shall test all backflow prevention devices.
7. Your public water system is required to establish a record keeping system for all the documents,
correspondences and forms related to the Cross-connection Control Program.
Upon completing this form, sign and return it with the supporting documents to: MassDEP - Drinking
Water Program, One Winter Street, 5th. Floor, Boston, MA 02108 Attn.: TNC/NTNC CCCP Plan
Once approved, this form and the appropriate documentation becomes your “Cross Connection
Control Program Plan” for your system as required by 310 CMR 22.22(3)(b).
If you have any question(s), please contact Mr. Otavio DePaula-Santos at (617) 556-1085 or via e-mail at
Otavio.Paula-Santos@state.ma.us
IV. PWS RESPONSIBLE PARTY
I certify under penalty of law that I am the owner or person authorized to fill out this form and that the
information contained herein is true, accurate, and complete to the best of my knowledge and belief.
Name ___________________________________________
Title __________________________
(Print)
Signature ____________________________________
Date ______/_____/______
FOR MassDEP USE ONLY:
CROSS-CONNECTION CONTROL PROGRAM PLAN:
APPROVED
DENIED
Comments: ________________________________________________________________________
___________________________________________________________________________________
MassDEP STAFF:
Name: _____________________________________
Title: _____________________________
Signature: ________________________________
Date: _____/_____/_______
W:/BRPDWP/Staff/OPaula-Santos/Xconn/TNC-NTNC CCCP Plan Approval/ CCCP Plan Questionnaire for TNC & NTNC rev 2021-09-23
Page of 3