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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 /> PART III: PROPOSED BACKFLOW CORRECTIVE ACTIONS AND SCHEDULE <br /> For each location identified in Part II above where there is currently no backflow prevention, the <br /> table below identifies: <br /> a. The method proposed to be implemented that will prevent backflow, and <br /> b. A schedule to install the preventive measure. <br /> If there are no current or potential backflow problems identified in Part II above, this Part does not <br /> need to be completed. <br /> Location With No Proposed Backflow Prevention Schedule to Install Proposed <br /> Current Backflow Method Backflow Prevention Method <br /> Prevention <br /> N/A <br /> PART IV: DOCUMENTATION OF EXISTING BACKFLOW CONDITIONS AND PROPOSED <br /> BACKFLOW PREVENTION METHODS <br /> As a trained professional in backflow prevention, I certify that, based on the information provided <br /> to me by the Discharger named above and my personal examination of the wastewater system, <br /> the above information in Part 11 above is true, accurate, and complete and the proposed backflow <br /> prevention method in Part 111 above will be effective to prevent the backflow of wastewater into a <br /> water supply well, irrigation well, or surface water at the dairy named in Part I above. <br /> QUALIFICATIONS OF TRAINED PROFESSIONAL(EDUCATION AND/OR EXPERIENCE) <br /> SIGNATURE OF TRAINED PROFESSIONAL DATE <br /> PRINT OR TYPE NAME <br /> Page 3 <br />