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Recycled Water Program - Annual Self-Inspection Report

  1. All check marks in a box marked with an asterisk (*) require explanations. Please use comment sections to provide a detailed explanation. 

  3. 1. Have any repairs or alterations been made to the recycled water system and/or to the adjacent potable water system since the date of last inspection? If yes, please provide us with a detail of those changes.*
  4. 2. Are all personnel dealing with the recycled water system educated on the basics of recycled water use? If no, please contact the city for training options. *
  5. 3. Has your site supervisor changed? If Yes, please provide us with the site supervisor contact information. If the new site supervisor is not certified please contact us to enroll in training.*
  6. 4. Do you have copies of “as built” drawings of the irrigation system that is served by recycled water? If no, please contact us. *
  8. 5. Is there evidence of recycled water runoff from this site? If yes, please note the location and nature of the problem. *
  9. 6. Is there evidence of recycled water ponding, and/or evidence of mosquitoes breeding within the irrigation area due to ponded water? If yes, please note the location and nature of the problem. *
  10. 7. Are identification signs, tags, and stickers and above ground pipe marking properly posted to inform the public that the irrigation water is recycled? If no, please indicate how you will correct the problem. *
  11. 8. Is there evidence of broken or otherwise faulty drip irrigation system emitters or spray irrigation sprinklers? If yes, please note the location, nature of the problem, and how it will be corrected. *
  12. 9. Is there evidence of leaks or breaks in the irrigation piping or tubing? If yes, please note location, nature of the problem, and how it will be corrected. *
  14. 10. Is the potable water backflow device in place? If no, please provide explanation.*
  15. 11. Have potable water backflow preventers been tested in the last 12 months? *

    I have attended the City’s Site Supervisor Training, am the certified Site Supervisor for this site, and that the information in this report and any attachments submitted, to the best of my knowledge, comply with the City of Santa Rosa rules and regulations for recycled water use, including the stipulations of the City Potable and Recycled Water Code, the Recycled Water Use Permit and the Recycled Water User’s Guide. 

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