Title Page

  • Facility Name

  • Address
  • Type of Establishment

  • Date

  • Inspector

Cross Connection Survey

    Add entry
  • Facility Type

  • Facility Service Number

  • Equip/Fixture Info/Type:

  • Location:

  • Hazard Level

  • Add Backflow Preventer
  • Serial Number:

  • Type:

  • Manufacturer:

  • BFP Location:

  • Comments:

  • Violation

  • Deficiency

  • Select one

  • Select one

  • Select one

  • Recommendation:

  • Comments:

  • Follow up
  • Follow up notes:


  • Add Photo

  • Comments


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

  • Are all inspected cross connections adequately protected?

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

  • Comments

  • Inspector's Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.