the end of the reporting year _____. Describe the PWS’s CCC Program plan, policies, or procedures at Part 1: Public Water System (PWS) Identification PWS ID: PWS Name: County: Part 2: Cross-Connection Control (CCC) Program Characteristics Type of Program Currently Implemented Type of Program Check One Premises isolation only. Combination program: reliance on both premises isolation and in-premises protection. In transition from a combination program to a premises isolation-only program. Coordination with Authority Having Jurisdiction (AHJ) on Cross-Connection Issues Indicate the status of coordination with AHJs in your service area. The AHJ is the entity that enforces the Uniform Plumbing Code. Check one box in each of last three columns for each AHJ in your service area. AHJ PWS currently: If Not Name of AHJ No. Coordinating, Coordinates Has Written (e.g., the City or did AHJ Decline with AHJ Agreement County Building Department) to Coordinate? with AHJ 1 Y N Y N Y N 2 Y N Y N Y N 3 Y N Y N Y N 4 Y N Y N Y N 5 Y N Y N Y N 1 If more than 5 AHJs, attach separate sheet providing the above information. Corrective or Enforcement Actions Available to the Purveyor Type of Corrective Action Indicate Whether Most Often Used Available (check one) Denial or discontinuance of water service. Y N Purveyor installs backflow preventer and bills customer. Y N Assessment of fines (in addition to elimination or control of cross Y N connection). Other corrective actions (describe): Y N Y N
Describe the PWS’s CCC Program plan, policies, or procedures at the end of the reporting year _____. Part 1: Public Water System (PWS) Identification PWS ID: PWS Name: County: Part 2: Cross-Connection Control (CCC) Program Characteristics Type of Program Currently Implemented Type of Program Check One Premises isolation only. Combination program: reliance on both premises isolation and in-premises protection. In transition from a combination program to a premises isolation-only program. Coordination with Authority Having Jurisdiction (AHJ) on Cross-Connection Issues Indicate the status of coordination with AHJs in your service area. The AHJ is the entity that enforces the Uniform Plumbing Code. Check one box in each of last three columns for each AHJ in your service area. AHJ No. Name of AHJ (e.g., the City or County Building Department) PWS currently: If Not Coordinating, did AHJ Decline to Coordinate? Coordinates with AHJ Has Written Agreement with AHJ 1 Y N Y N Y N 2 Y N Y N Y N 3 Y N Y N Y N 4 Y N Y N Y N 5 Y N Y N Y N 1 If more than 5 AHJs, attach separate sheet providing the above information. Corrective or Enforcement Actions Available to the Purveyor Type of Corrective Action Indicate Whether Available Most Often Used (check one) Denial or discontinuance of water service. Y N Purveyor installs backflow preventer and bills customer. Y N Assessment of fines (in addition to elimination or control of cross connection). Y N Other corrective actions (describe): Y N Y N
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