Report Backflow Incidents

These reported incidents will be reviewed and confirmed by the CCCC before they are posted on this website. The Cross Connection Control Committee will respect any individual wishing to remain anonymous, but will require verification of any incident reported by that person. In order to ensure that safe drinking water remain a priority of this committee, we encourage everyone to report any knowledge of a backflow incident, so the Health Authorities, and the Public are made aware of this health hazard.

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Reporting Agency*
Report Date*	YYY/DD/MM
Reported By:
First Name*
Last Name*
Title/Position*
Email Address*
Address
City
Province
Postal Code
Phone (business)
Fax
Incident:
Date of Incident
Time of Occurrence
General Location	(street)
Origin of backflow
Name of Premise
Street Address
Contact Person
Type of Business
Distribution of Contaminants
Contained within customer’s premise	Yes No
Description of Contaminant
Illness Reported

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