Mailing Address: THE CITY OF CALGARY
WATER SERVICES #435
PO BOX 2100 STN M
CALGARY AB T2P 2M5
EMAIL: crossconnection@calgary.ca
CROSS CONNECTION CONTROL
TEST REPORT
Reset
E 1059 (R2014-09)
ADDRESS OF DEVICE
OCCUPANT
OWNER
CONTACT
TELEPHONE NUMBER
(
ADDRESS OF OWNER
POSTAL CODE
SERIAL NUMBER
MAKE
MODEL
REPLACES SERIAL # BUILDING
LOCATION OF ASSEMBLY (ie. ROOM NUMBER)
TYPE OF TEST
INITIAL REPAIR
TESTER'S AWWA NUMBER
TELEPHONE NUMBER
(
SIZE
)
INSTALL DATE
YYYY
PREMISES-ISOLATING DEVICE
DOMESTIC
INTERNAL DEVICE
TESTER'S EQUIPMENT NUMBER
FIRE
IRRIGATION
TELEPHONE NUMBER
BUSINESS ADDRESS
)
FAX NUMBER
POSTAL CODE
(
AAG
CHECK VALVE 2
RP / RPF ASSEMBLY
(2 x Dia.)
RELIEF VALVE FAILED TO OPEN
CHECK VALVE 1
LEAKED
LEAKED
CLOSED TIGHT
CLOSED TIGHT
DCVA, DCVAF, SCVAF
CHECK VALVE 1 CHECK VALVE 2 AIR INLET VALVE
AG Size BUFFER (3 psi or greater)
A-B=C
=C __________________ Psi kPa _________ Psi kPa _________ Psi kPa
in
kPa
TEST RESULT
______mm STATIC INLET LINE PRESSURE AT TIME OF TEST _______________________________ Psi
PASSED
FAILED
AAG
)
PVB / SRPVB ASSEMBLY
T Outlet Dia.
LEAKED
LEAKED
E in PRESSURE DIFFERENTIAL ACROSS 1st CHECK VALVE (no flow) A __________________ Psi kPa
CLOSED
TIGHT
CLOSED TIGHT
S
______mm
OPENED, OPENING POINT OF RELIEF VALVE (2 psi or greater)-B __________________ Psi kPa Pressure Drop
Pressure Drop
T
R
E
P CHECK APPLICABLE VALVE(S)
A
I CHECK APPLICABLE REPAIR
R
DD
OTHER __________________________________________
TESTER'S NAME
(
BUSINESS NAME
MM
INSTALLED ON WHAT SYSTEM
INSTALLED ON
ANNUAL )
FAILED TO OPEN
CHECK VALVE
SHUT OFF
VALVES
#1
#2
LEAKED
LEAKED
CLOSED TIGHT
Pressure Drop
OPENED
CLOSED
_________ Psi kPa
YYYY
TEST DATE
MM
DD
If the device fails the initial test for any reason, complete the sections below, noting the repairs and retest results.
RELIEF VALVE
CHECK VALVE #1
CLEANED; REPLACED:
RP / RPF ASSEMBLY
DISC
CHECK VALVE 2
LEAKED
CHECK VALVE #2
SPRING
DIAPHRAGM
CHECK VALVE 1
LEAKED
SEAT
DCVA, DCVAF, SCVAF
AIR INLET VALVE
GUIDE
O-RINGS
SHUT OFF VALVE
POPPET
PVB / SRPVB ASSEMBLY
(2 x Dia.)
CHECK VALVE 1 CHECK VALVE 2 AIR INLET VALVE
CHECK VALVE
RELIEF VALVE FAILED TO OPEN
CLOSED TIGHT
CLOSED TIGHT
R
E Outlet Dia.
LEAKED
LEAKED
LEAKED
FAILED TO OPEN
T in PRESSURE DIFFERENTIAL ACROSS 1st CHECK VALVE (no flow) A __________________ Psi kPa
CLOSED TIGHT
CLOSED TIGHT
CLOSED TIGHT
E ______mm
OPENED, OPENING POINT OF RELIEF VALVE (2 psi or greater)-B __________________ Psi kPa Pressure Drop
Pressure Drop
Pressure Drop
S
OPENED
T
AG Size BUFFER (3 psi or greater)
_________ Psi kPa
A-B=C
=C __________________ Psi kPa _________ Psi kPa _________ Psi kPa
in
YYYY
kPa
RETEST DATE
RETEST RESULT
______mm STATIC INLET LINE PRESSURE AT TIME OF TEST _______________________________ Psi
PASSED
FAILED
REPAIR KIT
SHUT OFF
VALVES
#1
#2
LEAKED
CLOSED
MM
DD
DATE
YYYY
MM
DD
DATE
YYYY
MM
DD
I certify the above device has been tested in accordance with The City of Calgary Water Services Bylaw 40M2006, and Cross Connection Control Manual WC AWWA.
ISC: Unrestricted
SIGNATURE OF CERTIFIED TESTER
DATE
YYYY
MM
DD
SIGNATURE OF OWNER / TENANT
REMARKS/COMMENTS
FOR OFFICE
USE ONLY
DISTRIBUTION:
Submit
TESTING FREQUENCY
INSPECTOR'S SIGNATURE / COMMENTS
SEMI-ANNUALANNUAL TRI-ANNUAL
COPY 1 - Water Services, Cross Connection Control Office
COPY 2 - Certified Tester
COPY 3 - Occupant or Owner, this copy shall be retained on-site and available to the City of Calgary upon request.
The personal information on this form is collected under the authority of the Freedom of Information
and Protection of Privacy Act, Section 33(c), and is used solely for the purpose of information to
record test details and results. For additional information, contact Water Services at 3-1-1.