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UWM Permit Number Water Engineering Division Form 3 - Notice Regarding Cross Connection and Backflow Prevention Devices The City of Anaheim, Public Utilities Department (Utility) will not provide water service to any premises unless the public water supply is protected as required by State and County health regulations, and in accordance with the Utility’s Water Rates, Rules, and Regulations. Backflow protection devices shall be required for: multi- family domestic services; (ii) commercial and industrial domestic services; (iii) irrigation services; (iv) private fire protection services; and private domestic or fire services with two or more points of connection. The type and complexity of the backflow protection devices shall be determined by the Utility and shall be based on the potential degree of hazard. Backflow prevention devices shall be approved by the Foundation for Cross Connection Control and Hydraulic Research, University of Southern California, and shall be installed by and at the expense of the customer. The customer shall be responsible for maintaining the backflow protection device in a satisfactory operating condition and shall have the device tested at least once a year by an Orange County Health Department certified tester. If the device is found to be defective, the customer shall be responsible for repairing, overhauling, or replacing the backflow device. The customer shall keep records of such annual tests, repairs, or overhauls and forward copies to the Utility’s Cross Connection Control Program. The Utility, after giving written notice, may discontinue water services if: a backflow device is not tested on an annual basis; (ii) a device is found to be defective; (iii) a device has been repaired, removed, or relocated without subsequent testing; or (iv) an unprotected cross connection exists on the premises. Discontinued services will be restored only when such conditions or defects are corrected to the satisfaction of the Utility. The applicant acknowledges receipt of this notice and hereby agrees to notify the customer(s), property owner(s), and/or tenant(s) of their responsibility for maintaining, testing, and repairing backflow devices to be installed at the following location(s): Address/Location Quantity Size (inches) Type of Service (domestic/irrigation/fire) Applicant’s Name Applicant’s Signature Date If you have any questions on the backflow protection requirements, please contact the Utility’s Cross Connection Specialist at (714) 756-4280.