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