Cross Connection Survey

• Facility Name

• Address
  Address

• Type of Establishment

• Date

  Date

• Inspector

  Select Dustin White Josh Shafizadeh Other

  • Dustin White
  • Josh Shafizadeh
  • Other

Cross Connection Survey

Add entry

• Facility Type

  New Construction

  Existing Structure

  Remodel/Retrofit

• Facility Service Number

• Equip/Fixture Info/Type:

  Select Lawn Sprinkler System Fire Sprinkling System Boiler Chiller Main Supply Other

  • Lawn Sprinkler System
  • Fire Sprinkling System
  • Boiler
  • Chiller
  • Main Supply
  • Other

• Location:

• Hazard Level

  High

  Low
Add Backflow Preventer

• Serial Number:

• Type:

  Select Reduced Pressure Double Check Assembly Pressurized Vacuum Breaker Spill-Resistant Vacuum Breaker Vacuum Breaker (non-testable) Air Gap Check Valve Alarm Check/Check Valve Other

  • Reduced Pressure
  • Double Check Assembly
  • Pressurized Vacuum Breaker
  • Spill-Resistant Vacuum Breaker
  • Vacuum Breaker (non-testable)
  • Air Gap
  • Check Valve
  • Alarm Check/Check Valve
  • Other

• Manufacturer:

  Select Watts Apollo/ Conbraco Ames Wilkins Febco Other

  • Watts
  • Apollo/ Conbraco
  • Ames
  • Wilkins
  • Febco
  • Other

• BFP Location:

• Comments:

• Violation

  Yes

  No

• Deficiency

• Select one

  Back siphonage

  Back Pressure

  Back siphonage & Back pressure

  N/A

• Select one

  Potential Hazard

  Exisiting Hazard

  N/A

• Select one

  Improper Application

  Improper Installation

  N/A

• Recommendation:

• Comments:

Follow up

• Follow up notes:

Photos

Photos

• Add Photo

  Media

• Comments

Completion

• Have all Backflow Preventers been tested in accordance with State Regulations and Plumbing Code?

  Yes

  No

  N/A

• Are all inspected cross connections adequately protected?

  Yes

  No

  N/A

• In regards to Cross Connection Control is the facility ready for Certificate of Occupancy?

  Yes

  No

  N/A

• Comments

• Inspector's Name and Signature

  Sign