2. 

   
   

3. Report a Backflow Incident or 

   Potential Cross-Connection

   To report a backflow incident, leaking backflow prevention assembly, or potential cross-connection, please use this form (All fields are required).  

   
   

   For questions regarding the Cross-Connection Control Program, contact the City's Cross-Connection Specialist:

   • Phone: (408) 586-3328
   • E-mail: backflow@milpitas.gov
5. Date and Time of Incident
   Date and Time of Incident

   Date and Time of Incident
6. Please select the type of incident you are reporting

   1. Backflow Issue
   2. Potential Cross-Connection
8. How was the incident discovered?

10. Backflow Originated From:

12. Address or Location of Issue

    Street Number and Name

13. Unit Number
15. City
16. State
17. Zip Code
19. Nearest Cross-Street

21. Contact Information

23. Name
24. Email Address
26. Address

    Street Number and Name

27. City
28. State
30. Zip Code
31. Phone Number

    Include extension if applicable.

33. Tell us more - Please describe the incident in detail:
35. Service Connection Type (Select any/all that are applicable)

    1. Industrial
    2. Commercial
    3. Single-Family Residential
    4. Multi-Family Residential
    5. Irrigation

    1. Recycled Water
    2. Water System Facility
    3. Fire Line
    4. Other
37. If other, please describe.
39. Description and source of backflow substance (provide thorough description)
41. If available, please include an MSDS (Material Safety Data Sheet) or other chemical description form.
42. Upload any photos to help qualified personnel identify the concern.
44. END OF FORM. If you have trouble submitting this form or providing supplemental information, please e-mail backflow@milpitas.gov for support.
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field