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Cross Connections Forms

For Massachusetts' public drinking water systems.
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BRP WS 09 (English, PDF 192.09 KB)

This permit application is no longer required. Please contact your local water authority for instructions on the submittal of plans for the installation of backflow prevention devices (RPBP) or assemblies (DCVA).

WS 10 - Cross Connection Certification 
Cross-Connection Control Program Plan for Community Public Water Systems with Population ≥ 3,300 (English, DOC 424.5 KB)
Cross-Connection Control Program Plan Questionnaire for Small Community Public Water Systems with Population < 3,300 (English, PDF 219.44 KB)
Cross-Connection Control Program Plan Questionnaire for Non-Community Public Water Systems (Transient & Non-Transient [TNC & NTNC]) (English, PDF 152.72 KB)
Cross-Connection Survey Report Form (English, PDF 35.43 KB)
Backflow Prevention Device Inspection & Maintenance Report Form (English, PDF 147.96 KB)
Backflow Prevention Device Repair Information & Retest Report Form (English, PDF 168.81 KB)
Request for Public Water System Authorization to Delegate, Sub-delegate, Contract, or Sub-contract Cross Connection Surveyors Responsibilities (English, DOC 87.5 KB)

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