ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
 Regulation 11.39 Backflow Prevention and Cross Connection Control Rule
2
 ANNUAL REPORT V2.0
3
For January 1 - December 31,<ENTER COMPLIANCE YEAR>
4
Name of Water Supplier:
5
PWSID:
6
Completed by:
7
Date completed:Yellow Background = PWS Input ValueBlue Background = Excel Calculated Value
8
TypeLineValueQuestionReg 11
11.39(4)
9
 Survey1Number of NON-SINGLE-FAMILY-RESIDENTIAL service connections; commercial, industrial (wastewater treatment plant), agricultural, multifamily (tri-plex and larger), dedicated irrigation, dedicated fire, temporary construction, etc. Not required to survey or include in the survey compliance ratio calculation any service connection(s) identified after October 31, unless survey was completed.(i)
10
2Number of facilities or connections within Supplier's Waterworks with potable water that must be surveyed; treatment plants, pump stations, well houses, storage tanks, etc. (i)
11
30Total number of connections that MUST BE surveyed (Sum Line 1 + Line 2)(i)
12
4Number of required connections that HAVE BEEN surveyed to date. This includes connections that are protected by RPZ or Air-Gap (most protective assembly or method). (ii)
13
50.00Survey Compliance Ratio (Line 4/Line 3). Ranges from 0 to 1.0 (iii)
14
Question 5: Any number less than the ratio specified in Table 39-I is an automatic violation unless supplier received a department approved alternative survey ratio.
15
 Cross
Connections		6Number of ALL identified or potential cross connections; includes protected and unprotected, known and newly discovered, customer and supplier owned cross connections, and cross-connections identified at single family residences.(iv)
16
7Number of connections where service was suspended (locked off) for backflow noncompliance. This is the total number of suspensions which includes suspensions for: newly identified cross connections and cross connections with failed devices or methods not inspected.(viii)
17
8Number of identified uncontrolled cross connections and backflow assemblies that have failed their annual tests identified during the calendar year. (v)
18
9Number of identified uncontrolled cross connections and backflow assemblies that have failed their annual tests identified during the calendar year that WERE controlled within 120 days of discovery or a department approved alternative schedule. This includes cross-connections controlled by an assembly, method, or suspension of service. (v)(A)
19
10Number of identified uncontrolled cross connections and backflow assemblies that have failed their annual tests identified during the calendar year that WERE NOT controlled within 120 days of discovery or a department approved alternative schedule.(v)(B)
20
Question 10: Any number greater than 1 is an automatic violation unless supplier received a department approved alternative compliance schedule.
21
 Assemblies11Number of backflow prevention ASSEMBLIES that were used during the calendar year (installed at cross connections, corresponding to line 6). Includes all TESTABLE devices that had water flowing through them during the calendar year (even if service was suspended) Examples include RP, Double Check, Pressure Vacuum Breaker, etc. Also includes failed devices where service was suspended.(vi)
22
12Number of backflow prevention ASSEMBLIES used that were tested and passed by a Certified Cross Connection Control Technician during the calendar year (ix)
23
130Backflow Prevention Assembly Annual Testing Compliance Ratio (Line 12/Line 11)(x)
24
Question 13: After December 31, 2021, any number less than 0.90 is an automatic vilation and must be reported to the Department. SeeTable 11.39-II for additional ratio requirements.
25
14Number of backflow prevention assemblies NOT tested during the calendar year. Attach a list of untested assemblies and locations on a separate sheet. Beginning January 1, 2022, all assemblies not tested in the previous calendar year must be tested within 90 days after the active date of the assembly in the next calendar year.(xi)
26
 Methods15Number of backflow prevention METHODS that were used during the calendar year (installed at cross connections, corresponding to line 6) Includes all NON-TESTABLE ""devices"" (ex: Air Gap, Block & Bleed, Hose Bib Vacuum Breaker, Single Check, Dual Check Valve, Atmospheric Vacuum Breaker, Intermediate Atmospheric Vacuum Breaker, etc.) (vii)
27
16Number of backflow prevention METHODS that were inspected during the calendar year(xii)
28
170.00Backflow Prevention Method Annual Inspection Compliance Ratio (Line 16/Line 15) Must be greater than 0.90.(xiii)
29
Question 17: Any number less than 0.90 is an automatic violation and must be reported to the Department.
30
18Number of backflow prevention methods NOT inspected during the calendar year. Attach a list of non-inspected methods and locations on a separate sheet. All methods not inspected in the previous calendar year must be inspected within 90 days after the active date of the method in the next calendar year.(xiv)
31
 For additional guidance please refer to Policy 7 or the FAQ and guidance documents located at https://cdphe.colorado.gov/bpccc
32
 Submittal Requirements
33
The BPCCC annual report is due by May 1 of following year, however, it is not required to be submitted to the department unless a violation is identified.
The department will review the BPCCC annual report during sanitary surveys but reserves the ability to request it at any time.
34
If a BPCCC violation occurs, Regulation 11.39(7) requires that the violation(s) must be reported to the department no later than 48 hours after the violation(s) occurs. In accordance with Regulation 11.36(2)(b) the department will request that the supplier submit a copy of the BPCCC annual report documenting the identified violation. Please submit a copy of the BPCCC annual report via the department’s Drinking Water Portal which can be found at https://wqcdcompliance.com/login under the category "Sanitary Survey Inspection".
35
Please identify any violations demonstrated above.
Please include the reason for violations as well as any action taken or anticipated action to resolve the violation(s), including anticipated return to compliance date(s):
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100