Design Level Cross Connection Survey

Design Level Cross Connection Survey
(for building permit applications for all municipalities within Greater Victoria)
CRD
Use
Only Date Received Customer ID No Facility ID No Install ID No Test ID
Municipality (Please check � the following facility location)
Victoria Esquimalt Oak Bay Saanich Central Saanich
Sidney North Saanich Sooke East Sooke Metchosin
Colwood View Royal Langford Highlands
Backflow Preventer (BFP) Type Glossary
AG – Air Gap
RP – Reduced Pressure Principle Assembly
DC – Double Check Valve Assembly
AVB – Atmospheric Vacuum Breaker
PVB – Pressure Vacuum Breaker
DuC – Dual Check
Designated Facility Contact Person Info (Please fill out this section)
Contact Person Name Contact Person Title Contact Person Organization
Contact Person Mailing Address (Unit no, Street no, Street Name, City, Prov. Postal Code)
Contact Person Email Address Contact Phone No Contact Fax No Contact Cell No (other)
Facility Info (Please fill out this section)
Facility Name (Common name of building/structure of installed device ) Facility Type (See list on web site below)
Facility Unit No Facility Address (Street no, Street Name or Park Name,) Designer Project No
Facility Municipality Name of Owner or Organization Facility Hazard Level
Service Info (Please check � and fill out this section)
Combined Size:
Service Connection(s) and Water Meter Size (inch)
Design Line Pressure: (psi)
Domestic 1/2 3/4 1 1 ½ 2 3 4 6 8 10 Other
Fire 1/2 3/4 1 1 ½ 2 3 4 6 8 10 Other
Irrigation 1/2 3/4 1 1 ½ 2 3 4 6 8 10 Other
BFP Info (Please check � and fill out this section)
Water Usage
Auxiliary
Water
Supply
Fire
Sprinkler
System
Downstream
Process
Well or Surface
Water
Storage Tank
Reclaimed Water
Rainwater
Harvesting
Other
Anti-freeze (glycol
system)
Wet or Dry system
Other
BFP Type
(AG, AVB, PVB, RP, DC, DuC)
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
⇒ BFP Type:
Premises Isolation at the Water Meter?
Yes AG RPBA DCVA Other
No Explain
Fire Line RPBA DCVA Other ___
Location
(Floor Level, Room No, Equipment Tag, Etc)
⇒ Location:
⇒ Location:
⇒ Location:
⇒ Location:
⇒ Location:
⇒ Location:
⇒ Location:
⇒ Location:
Please Turn Over and Complete Other Side
Facility-Unit�(or) Zone Isolation
COMPLETE TWO Copies: ATTACH to: Municipality copy with Permit Application
MAIL or FAX to: CRD Integrated Water Services
Revised March 10, 2010 Cross Connection Control
Website www.crd.bc.ca/water/crossconnection 625 Fisgard Street, Victoria, BC V8W 2S6
CCC Forms - Design Level Survey.docx Tel: 250.474.9503 Fax: 250. 474.9672

BFP Info (cont’d) (Please check � and fill out this section)
Water Usage
Downstream
Process
BFP Type
Irrigation
System
Heating /
Cooling
Equipment
Commercial
Kitchen / Bar
Equipment
Commercial
Laundry /
Janitor and /
or Service
Rooms
Medical /
Dental and /
or Labs
Misc. (other
equip)
Chemical Injection
Non-Chemical Injection
Other
Boiler (water or steam)
Design Level Cross Connection Survey (cont’d)
Heat Exchanger (except Heat
exchangers with Visible Double Wall Leak Path)
Water Cooled Equipment
Other
Dish / Glass washer
Canopy / Hood washer
Beverage Carbonator
Icemaker
Other
Washing Machine
. Janitors sink with chemical
dispenser attachment
Dry cleaning Equipment
Detergent Dispenser
Other
Medical Equipment
Sink (inc lab sink)
Fume Hood (Lab)
Dental Equipment
Other
Hose Connection (all)
Reverse Osmosis
Water Filters
Car wash Equipment
RPBA
DCVA
RPBA
RPBA
RPBA
RPBA
RPBA
(SS)RPBA,(OR)RPBA
&(SS) DCAPC
RPBA
RPBA
RPBA
RPBA
RPBA
RPBA
RPBA
RPBA
RPBA
HCVB
RPBA
RPBA
RPBA
�������������Other �� ����
Location
(Floor Level, Room No, Equipment Tag, Etc)
Location: ____________________________________________
Location: ____________________________________________
Location: ____________________________________________
Location:
Location:________________________________________
Location: _______________________________________
Location:
Location:________________________________________
Location:________________________________________
Location:________________________________________
Location: ______________________________________
Location: _______________________________________
Location:
Location:
Location:
Location:_____________________________________________
Location: ____________________________________________
Location:_____________________________________________
Location:
Location:
Location:
Location:
Location:
Location:
Location:
Location:
Location:
Designer / Cross Connection Control Survey Specialist (Please fill out this section and sign below)
All internal cross connections protected? Yes No Designed to CAN/CSA B64-10? Yes No Version
Designer (please print) Telephone
Signature Date
COMPLETE TWO Copies: ATTACH to: Municipality copy with Permit Application
MAIL or FAX to: CRD Integrated Water Services
Revised March 10, 2010 Cross Connection Control
Website www.crd.bc.ca/water/crossconnection 625 Fisgard Street, Victoria, BC V8W 2S6
CCC Forms - Design Level Survey.docx Tel : 250-474-9503 Fax: 250- 474-9672