Cross Connection Survey

Required fields are marked with asterisks (*)

This form is intended to assist the Qualified Person in carrying out a survey to address potential cross-connection situations. It is the responsibility of the owner or building occupier to bring to the attention of the Qualified Person all water uses within the premises to permit inspection for potential cross connections and recommendation of corrective actions. All selections shall be made in accordance with the By-law No 6-2019 as amended (Backflow Prevention and Cross Connection Control) and current edition of CSA B64-10. The Municipality has jurisdiction over all selections. Survey subject to approval before work may commence. Permits are required for installation of all testable devices. Submit this survey online to the Municipality of Thames Centre and to the owner of the facility.

Notice of Collection of Personal Information

Personal information on this form is collected under the legal authority of Municipal Act, 2001. The delegate’s information is collected and maintained for the purpose of creating a record that is available to the general public, pursuant to Section 27 of the Municipal Freedom of Information and Protection of Privacy Act. This information is collected and maintained for the purposes of preparing an agenda for Council. Questions or concerns about the collection of this information can be directed to the Clerk at 4305 Hamilton Road, Dorchester ON N0L 1G3, Phone: 519-268-7334 ext 254 or clerk@thamescentre.on.ca

Date

Owner Name

Owner Phone Number

Owner Email

Building Address

Surveyor Name

Certificate Number

Surveyor Phone Number

Surveyor Email

Surveyor Company Name & Address

Building Use

You answered yes; State Use

N None Required	HCVB Hose Connection Vacuum Breaker
AVB Atmospheric type Vacuum Breaker	LFVB Laboratory Faucet Type Vacuum Breaker
DUC Duak Check Valve Type	SCVA Single Check Valve Assembly
DCAP Dual Check Valve Type w/Atmospheric Port	AG Air Gap
DCVA Double Check Valve Assembly Type	RP Reduced Pressure Principle
DUCV Dual Check Valve Type w/Intermediate Vent	PVB Pressure Type Vacuum Breaker
DCAPC Dual Check Valve Type w/Atmospheric Port for Carbonation Sys	OTH Other (will need to specify)

Location or Cross Connection (serving what equipment, etc.)

Existing Protection (Type & Size)

Serial Number

Date of Last Test

Proposed Upgrade (Type & Size)

Location or Cross Connection (serving what equipment, etc.)

Existing Protection (Type & Size)

Serial Number

Date of Last Test

Proposed Upgrade (Type & Size)

Location or Cross Connection (serving what equipment, etc.)

Existing Protection (Type & Size)

Serial Number

date of last test

Proposed Upgrade (Type & Size)

Location or Cross Connection (serving what equipment, etc.)

Existing Protection (Type & Size)

Serial Number

Date of Last Test

Degree of Hazard

Minor

Moderate

Severe

Proposed Upgrade (Type & Size)