Cross-Connection Survey Report Form - City of Brantford

Building Department __ Plumbing System APPENDIX C page 1City Hall, 100 Wellington Sq __ Fire System Cross Connection SurveyBrantford, Ontario, N3T 5R7 __ Irrigation SystemPhone: 519-759-4150 Date of Audit:Fax: 519-752-1874 _____/_____/20_____Facility Name: _____________________________________Address: _____________________________________________________Property/Business Owner: _____________________________________Phone# Hazard Level: Low ___ Moderate ____ Severe ____Surveyor Name: _________________________________________________Phone#: Company: _________________________________123Location of Cross ConnectionService what equip. etc.AcceptableProtectionY/N?Serial Numberof Exist. DeviceRequired Upgradefrom list of BFPdevices belowRemarksI, the undersigned, hereby declare that to the best of my knowledge, the information contained herein is complete and accurate.Surveyor's Signature:_________________________________________________________ Date: __________________________5 Year Renewal? o Initial Survey? o If initial survey was checked off, survey completion is MANDATORY unless choosing to install an RP.If "5 Year Renewal " was checked off, were any process or operational changes made in the last 5 years? Yes __________ No __________If yes, complete the survey. If no, Owner may forego completion of survey and sign below:I, the undersigned, hereby declare that to the best of my knowledge, the information contained herein is complete and accurate.Owner's Signature: ________________________________________________________ Date: ___________________________NOTE:Identifications of any cross-connections shall be made in accordance with the City of BrantfordBackflow Prevention Bylaw. All selections shall be made in accordance with the CSA B64. 10-94, asamended OR consult with the City of Brantford, Building Department. The City reserves the right toapprove of all selections. Survey subject to approval before work may commence. Permits arerequired for installation of all testable devices. Submit copies of this survey to Building Dept. andOwner of facility within 14 days of audit. Use the abbreviations provided for listing requiredupgrades and existing device.AG - Air GapAVB - Atmospheric Vacuum BreakerDCAP - Dual Check Valve withAtmospheric PortDuC - Dual Check ValveDUCV - Double Check with AtmosphericPortHCVB - Hose Connection VacuumBreakerLFVB - Lab Faucet Vacuum BreakerN - NoneNOTE: Any non-conventional device that is installed shall be identified and the rationale be specified under "REMARKS".LACV - Listed Alarm Check ValveDCVA - Double Check Valve AssemblyPVB - Pressure Vacuum BreakerRSCV - Resilient Seated Check ValveRP - Reduced Pressure Principle* Owner is responsible for allapplicable permits.

Building Department __ Plumbing System APPENDIX C page 2City Hall, 100 Wellington Square __ Fire System Cross Connection SurveyBrantford, Ontario, N3T 5R7 __ Irrigation SystemPhone: 519-759-4150Fax: 519-752-18744567891011121314151617181920Location of Cross ConnectionService what equip. etc.AcceptableProtectionY/N?Serial Numberof Exist. DeviceRequired Upgradefrom list of BFPdevices belowRemarks