Fillable CROSS CONNECTION CONTROL BACKFLOW PREVENTER TEST REPORT cccontrol@utilitieskingston.com (Utilities Kingston)

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CROSS CONNECTION CONTROL BACKFLOW PREVENTER TEST REPORT cccontrol@utilitieskingston.com (Utilities Kingston)

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Facility Address
Any false information or misleading statements made on this report will render any approval granted by the City of Kingston and Utilities Kingston null and void and may
result in removal of the certified tester and/or testing company from the Utilities Kingston Cross Connection Control database of approved testers.
DRINKING WATER SYSTEMS
CROSS CONNECTION CONTROL
BACKFLOW PREVENTER TEST REPORT
cccontrol@utilitieskingston.com
CCCP Office - 85 Lappan's Lane
VERSION DATE: OCTOBER 23, 2019
City
Postal Code
Owner Address
City
Postal Code
To be submitted by the property owner of an industrial, commercial, institutional, or multi-residential building. This test report form and tests must
be completed by a certified tester under Utilities City of Kingston Water BY-LAW and in accordance with CSA B64 Standard. In addition, the City
of Kingston requires a BUILDING PERMIT to be obtained before any backflow prevention installation.
Is this BFP device for premises isolation?
FACILITY AND OWNER INFORMATION
LOCATION DETAILS AND HAZARD LEVEL
YES NO
Number of BFP devices for premises isolation
Are there any hose or other connections ahead of
Premises Isolation Backflow Preventer?
YES
NO
Water Meter Number
Is this BFP device on a fire system?
YES NO
Is there a by-pass line around the meter?
YES NO
Is the by-pass protected by the premises BFP?
(Is the premises BFP downstream of the bypass?)
YES
NO
SEVERE MODERATE MINOR
HAZARD LEVEL OF INSTALLATION
BACKFLOW PREVENTER DETAILS
Serial Number
Manufacturer Model
Installation Date (YY/MM/DD)
Pipe Size
Tagged With a
UK Tag?
YES NO
GENERAL TEST INFORMATION
Location of Assembly (i.e. Room number)
Tester Name Certification number
Company Name Telephone
Postal Code Address
Test Kit Serial number Manufacturer
Model Calibration Date
Type of BFP Device
Type of Test
Device Orientation
PO Box 790
Kingston, ON Canada
K7L 4X7
Phone: 613-546-1181 x 2196
Fax: 613-544-9842
www.utilitieskingston.com/water/programs/cccp
Does the facility have a fire system?
YES NO
Is the by-pass valve sealed in the off position?
YES
NO
Occupant/Company
Telephone
Email
Owner
Telephone
Email
Successful Test Date
Horizontal Vertical
Has it been removed?
Tag Number
New Annual Replace
Old Serial
Number
YES NO
PAGE 1 OF 2
Building permit number for all new installations
Any false information or misleading statements made on this report will render any approval granted by the City of Kingston and Utilities Kingston null and void and may
result in removal of the certified tester and/or testing company from the Utilities Kingston Cross Connection Control database.
UTILITIES KINGSTON - DRINKING WATER SYSTEMS - CROSS CONNECTION CONTROL - BACKFLOW PREVENTER REPORT
TEST DETAILS
VERSION DATE: OCTOBER 23, 2019
PAGE 2 OF 2
Check Valve 1 Check Valve 2Relief Valve
Leaked
Closed Tight
Leaked
Closed Tight
Check Valve 1 Check Valve 2
Leaked
Closed Tight
Pressure Differential
Across Check
Air Inlet Valve Check Valve
Failed to Open
Opened
Leaked
Closed Tight
Downstream Shut Off Valve Leaked Closed Tight
RETEST DETAILS
FAILED
PASSED
TEST
RESULTS
REPAIR - If the backflow preventer fails the initial test for any reason complete repair and retest
Check Applicable Valve(s)
Check Applicable Repair:
Relief Valve Check Valve 1 Check Valve 2 Air Inlet Valve Shut Off
General Inspection, Cleaning and Servicing
Seat O-Rings Poppet Repair Kit
CERTIFICATION OF TEST RESULTS
I certify that I have tested the device identified on this report in accordance with the Utilities Kingston Backflow Prevention
Control Program and as specified by the CSA B64 standard and that the information provided is true and accurate.
INSPECTOR'S COMMENTS
DCVA, DCVAF, SCVAF Serial Number PVB / SRPVB Assembly Serial number
RP / RPF Assembly Serial Number
Buffer (min. 3 psi)
Relief Valve Open Value (min.2 psi)
Leaked
Closed Tight
Test Date
Static Inlet Pressure at Time of Test (Required for Pass)
Check Valve 1 Check Valve 2
Leaked
Closed Tight
Leaked
Closed Tight
Check Valve 1 Check Valve 2
Leaked
Closed Tight
Air Inlet Valve Check Valve
Failed to Open
Opened
Leaked
Closed Tight
Downstream Shut Off Valve Leaked Closed Tight
FAILED
PASSED
TEST
RESULTS
DCVA, DCVAF, SCVAF Serial number PVB / SRPVB Assembly Serial number
RP / RPF Assembly Serial number
Leaked
Closed Tight
Re-Test Date
Static Inlet Pressure at Time of Test (Required for Pass)
Pressure Differential Across
Check Valves (no flow)
Check Value 1
Check Value 2
Pressure Differential Across
Check Valves (no flow)
Check Valve 1 Check Valve 2
Parts Replaced:
Parts Replaced (Check applicable below)
Failed to Open
Opened
Relief Valve
Failed to Open
Opened
Relief Valve Open Value (min.2 psi)
Buffer (min. 3 psi)
Other:
Pressure Differential
Across Check
Pressure Differential
Across Check
Opened
(at Pressure)
Opened
(at Pressure)
Pressure Differential
Across Check
Pressure Differential
Across Check
Pressure Differential
Across Check
Certified Tester Name
DateCertified Tester Signature
Date
Owner / Owner Representative
/ Occupant Signature
Owner / Owner Representative / Occupant
(Please Print)
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CROSS CONNECTION CONTROL BACKFLOW PREVENTER TEST REPORT cccontrol@utilitieskingston.com (Utilities Kingston)

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Completed 7 June 2021

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