Cross Connection Control
Testing and Inspection Report
Shuswap Indian Band
Unit 1A Arrow Road, Invermere, BC V0A 1K0
Tel: (250) 341-3678 • Fax: (250) 341-3683 • Email: building@kinbasket.net
Development and Building Department
Address of Device
Occupant
Owner
Contact
Telephone Number
Address of Owner
Serial Number
Make
Postal Code
Model
SIze
Install Date
Installed on What System
DOmestic
Building
YYYYMMDD
Telephone Number
Location of Assembly (ie. Room Number)
FIre
Irrigation
Tester’s AWWA Number
Other______________________________________________
Tester’s Equipment Number
Business Name
Tester’s Name
Telephone Number
Business Address
Postal Code
Type of Test
Fax Number
Type of Device
Initial
Annual
Repair
RP / RPS Assembly
Relief Valve failed to open
Replaces Serial #_ ______________________________________
check Valve 2
Check Valve 1
Leaked
Closed Tight
Leaked
Closed Tight
T
E Pressure Differential across 1st check Valve (no flow)
S
Opened, Opening point of Relief Valve (2 psi or greater)
T
A-B=C
Buffer (3 psi or greater)
R
E
P Check Applicable Valve(s)
A
I
Check Applicable Repair
R
PVB
Check Valve 1
Psi kPa
- B__________________
Psi kPa
=C__________________
Psi kPa
Check Valve 2
SRPVB
RPF
DCVAF
PVB / SRPVB Assembly
Air Inlet Valve
SCVAF
Shut Off Valves
Check Valve
#1
#2
Leaked
Leaked
Failed to open
Leaked
Leaked
Closed Tight
Closed Tight
Opened
Closed Tight
Closed
Test Result
Passed
YYYYMMDD
Test DATE
Failed
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 / RPS Assembly
Disc
Check Valve 1
Leaked
Closed Tight
Leaked
Closed Tight
A-B=C
Check valve #2
Spring
check Valve 2
Relief Valve failed to open
R
E
T Pressure Differential across 1st check Valve (no flow)
E
S Opened, Opening point of Relief Valve (2psi or greater)
T
Buffer (3psi or greater)
DCVA
DCVA, DCVAF, SCVAF
A__________________
kPa
Static Inlet Line Pressure at time of Test ___________________________________ Psi
RP
Diaphragm
DCVA, DCVAF, SCVAF
Check Valve 1
A__________________
Psi kPa
- B__________________
Psi kPa
=C__________________
Psi kPa
kPa
Static Inlet Line Pressure at time of Test ___________________________________ Psi
Seat
Check Valve 2
Air Inlet Valve
Guide
Shut off valve
O-Rings
Poppet
Repair Kit
PVB / SRPVB Assembly
Air Inlet Valve
Shut Off Valves
Check Valve
#1
Leaked
Leaked
Failed to open
Leaked
Leaked
Closed Tight
Closed Tight
Opened
Closed Tight
Closed
RETest Result
Passed
Failed
#2
YYYYMMDD
RETest DATE
I certify the above device has been tested in accordance with the Shuswap Indian Band Cross Connection Control specifications.
Signature of Certified Tester
Date
YYYYMMDD
Signature of owner / Tenant
Date
YYYYMMDD
Remarks/Comments
For Office
Use only
Distribution:
Testing Frequency
Semi-Annual
White - Cross Connection Control Officer
Inspector’s Signature
Annual
Bi-Annual
Canary - Certified Tester
Tri-Annual
Pink - Occupant or Owner
Date
YYYYMMDD