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FORM FOR DOCUMENTING BACKFLOW PREVENTION OFcw <br /> UNDER Y <br /> WASTE DISCHARGE REQUIREMENTS GENERAL ORDER NO. R5-2013-0122 <br /> FOR <br /> EXISTING MILK COW DAIRIES <br /> f �OeiiL�� <br /> PART II: IDENTIFICATION OF EXISTING BACKFLOW CONDITIONS <br /> The attached Site Map identifies all of the locations in the Production Area and all Land <br /> Application Areas under the control of the Discharger at the dairy identified in Part I above where <br /> there are cross-connections that could, or do, allow the backflow of wastewater into a water <br /> supply well, irrigation well, or surface water. For each location shown on the map, the table <br /> below describes: <br /> a. How and where wastewater can potentially, or does, backflow to a groundwater supply <br /> and/or surface water supply (if there are no current or potential backflow problems, indicate <br /> so with "none"), and <br /> b. How backflow of process wastewater into the groundwater or surface water supply is <br /> currently prevented (if there is no current prevention method, indicate so with "none"). <br /> Location Where How Backflow Can or Does Current Backflow Preventive <br /> Backflow can Occur Occur Measure <br /> Irrigation Well #1 None Double Chemigation Valve <br /> Irrigation Well #2 None Double Chemigation Valve <br /> Page 2 <br />