THE CORP. OF THE CITY OF CAMBRIDGE
Planning Services Department
50 Dickson Street, P.O. Box 669
Cambridge ON N1R 5W8
Tel: 519-740-4613 Fax: 519-622-6184
CROSS CONNECTION CONTROL
TESTING AND INSPECTION REPORT
ADDRESS OF DEVICE
OCCUPANT
OWNER
CONTACT
ADDRESS OF OWNER
SERIAL NUMBER
MAKE
POSTAL CODE
MODEL
SIZE
INSTALLED ON WHAT SYSTEM
DOMESTIC
IRRIGATION
TESTER’S KIT CALIBRATION DATE
DD
BUILDING
TELEPHONE NUMBER
BUSINESS ADDRESS
FAX NUMBER
POSTAL CODE
TYPE OF DEVICE
ANNUAL
REPAIR
REPLACES SERIAL #__________________________________________________
CHECK VALVE 2
RP/RPF ASSEMBLY
RELIEF VALVE FAILED TO OPEN
CLOSED TIGHT
CLOSED TIGHT
CHECK VALVE 1
A _______________________ Psi kPa
-B _______________________ Psi kPa
=C _______________________ Psi kPa
A-B=C
kPa
STATIC INLET LINE PRESSURE AT TIME OF TEST __________________________________________ Psi
DCVA
PVB
SRPVB
DCVA, DCVAF, SCVAF
LEAKED
OPENED, OPENING POINT OF RELIEF VALVE (2 psi or greater)
RP
CHECK VALVE 1
LEAKED
PRESSURE DIFFERENTIAL ACROSS 1st CHECK VALVE (no
BUFFER (3 psi or greater)
CHECK VALVE 2
LEAKED
LEAKED
CLOSED TIGHT
CLOSED TIGHT
DIFF psi
DIFF psi
TEST RESULT
PASSED
RPF
DCVAF
PVB / SRPVB ASSEMBLY
AIR INLET VALVE
SHUT OFF VALVES
CHECK VALVE
FAILED TO OPEN
#1
LEAKED
CLOSED
DIFF psi
FAILED
#2
LEAKED
CLOSED TIGHT
OPENED
SCVAF
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
CHECK APPLICABLE VALVE(S)
CHECK APPLICABLE REPAIR
RELIEF VALVE
CLEANED; REPLACED:
RELIEF VALVE FAILED TO OPEN
DISC
OPENED, OPENING POINT OF RELIEF VALVE (2 psi or greater)
A-B=C
SPRING
CLOSED TIGHT
CLOSED TIGHT
A _______________________ Psi kPa
-B _______________________ Psi kPa
=C _______________________ Psi kPa
kPa
STATIC INLET LINE PRESSURE AT TIME OF TEST __________________________________________ Psi
I certify the above device has been tested in accordance with The City of Cambridge
DIAPHRAGM
CHECK VALVE 1
SEAT
CHECK VALVE 2
LEAKED
LEAKED
CLOSED TIGHT
CLOSED TIGHT
DIFF psi
RETEST RESULT
SHUT OFF VALVE
AIR INLET VALVE
GUIDE
DCVA, DCVAF, SCVAF
LEAKED
DIFF psi
PASSED
O-RINGS
POPPET
REPAIR KIT
PVB / SRPVB ASSEMBLY
AIR INLET VALVE
FAILED TO OPEN
OPENED
FAILED
SHUT OFF VALVES
#1
CHECK VALVE
LEAKED
LEAKED
CLOSED TIGHT
CLOSED
DIFF psi
RETEST DATE
#2
YYYY
MM
DD
MM
DD
MM
DD
Bylaw 146-03
DATE
SIGNATURE OF CERTIFIED TESTER
CHECK VALVE #2
CHECK VALVE 1
LEAKED
PRESSURE DIFFERENTIAL ACROSS 1st CHECK VALVE (no
BUFFER (3 psi or greater)
CHECK VALVE #1
CHECK VALVE 2
RP/RPF ASSEMBLY
R
E
T
E
S
T
MM
TESTER’S NAME
TYPE OF TEST
R
E
P
A
I
R
YYYY
OTHER __________________________________________
BUSINESS NAME
INITIAL
INSTALL DATE
FAX NUMBER
LOCATION OF ASSEMBLY (i.e. ROOM NUMBER)
FIRE
TESTER’S OWWA NUMBER
T
E
S
T
TELEPHONE NUMBER
YYYY
MM
DD
SIGNATURE OF OWNER / TENANT
DATE
YYYY
REMARKS/COMMENTS
INSPECTOR’S SIGNATURE
FOR OFFICE
USE ONLY
DISTRIBUTION:
WHITE - Cross Connection Control
CANARY Tester
- Occupant or Owner
DATE
YYYY
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 the City’s Corporate Records Co-ordinator/Deputy Clerk in the Clerk’s Division at 519-740-4680, Ext. 4583