Recycled Water Use Site Annual Inspection Check List

Customer Number (required)

Account Number (required)

Customer Name (required)

Service Location (required)

Please place a check in the box next to a requirement to indicate compliance. (required)

 Signage indicating that recycled water is being used for irrigation is located at points where the public may enter the use area.

 Potable water facilities in close proximity to the recycled water system are identified and labeled (e.g. hose bibs).

 Components of the recycled water irrigation system are identified with appropriate signage or marking to notify those persons working on or using the system as to the source of the water being used (incl. Storage tanks or ponds, meters, valve boxes and valves, automatic controllers, quick couplers, pumps).

 There is no ponding of recycled water as a result of irrigation.

 Overspray and runoff of recycled irrigation water outside of the design area has been minimized.

 A 24-hour negative pressure shutdown test of the on-site recycled water system has been performed to verify the absence of cross connections with any potable water system.

Date of 24-hour negative pressure shutdown test (required)

I, Site Supervisor of the above-mentioned recycled use site, hereby certify that the current conditions at this facility are as indicated above.

Site Supervisor Name (required)

Phone Number (required)

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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Recycled Water Use Site Annual Inspection Check List

Recycled Water Site Supervisor Information

Cross Connection Program and Backflow Assemblies