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DRINKING WATER SYSTEMS CROSS CONNECTION CONTROL SURVEY cccontrol@utilitieskingston.com (Utilities Kingston)

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Facility Address
Contact
City Telephone
Email Postal Code
Owner address
Owner
City Telephone
Email Postal Code
FACILITY AND CONTACT INFORMATION
SURVEY COMPLETED BY
Tester Name Certification Number
Company Name Telephone
Postal Code Address
GENERAL SURVEY INFORMATION
Survey Date
Is there a fire protection
system?
NOYES
Type of Water Use: COMMERCIAL
INDUSTRIAL
INSTITUTIONAL MULTI-RESIDENTIAL
Nature of Business
Is there premises isolation for the fire protection
system?
NOYES
CONNECTIONS
Location
Equipment Connected to or Serving
Existing Device Type / Serial number
Device Upgrade Recommended by Tester
MINOR MODERATE SEVERE
Hazard Level
Acceptable Protection in Place per City
of Kingston By-Law No. 2006-122?
YES - NOTE: If Yes, test reports must be submitted for devices used for premises
protection.
NO
Service
Connection
Cross
Connection
Please use these codes to identify types of backflow prevention
AG - air gap AVB - atmospheric vacuum breaker DCAP - dual check valve with atmospheric port
DCVA - double check valve assembly DuC - dual check valve DuCV - double check with atmospheric port
HCVB - hose connection vacuum breaker LFVB - lab faucet vacuum breaker PVB - pressure vacuum breaker
RP - reduced pressure principle RSCV - resilient seated check valve
Meter Number
Device Required for:
Zone
Protection
Fire System
Connection
Connection Number
Fixture
Protection
Premises
Protection
Any false information or misleading statements made on this survey 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 SURVEY
cccontrol@utilitieskingston.com
CCCP Office - 85 Lappan's Lane
VERSION DATE: OCTOBER 23, 2019
FULL DISCLOSURE REQUIRED: This form is intended to assist the Certified Tester in carrying out a survey and is not to be construed as addressing all potential cross
connection situations. It is the responsibility of the owner or occupant to bring to the attention of the Certified Tester all water uses within the premises to permit inspection for
potential cross connections, and to enable the Certified Tester to determine the hazard classification. If premises already defined as high hazard and using zone protection, the
survey must, at minimum, determine the required backflow preventer required on all water lines and possible bypasses which service the building.
PO Box 790
Kingston, ON Canada
K7L 4X7
Phone: 613-546-1181 x 2196
Fax: 613-544-9842
www.utilitieskingston.com/Water/Programs/CCCP
Report continued on page 2.
PAGE 1 OF 2
For additional connections attach additional copies of this page and re-number connections as applicable
REPORT SUMMARY AND COMPLETION
Additional Premises Protection Required?
YES - Describe Below
NO
Owner / Owner Representative / Occupant (Please Print) Owner / Owner Representative / Occupant Signature Date
Any false information or misleading statements made on this survey 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.
CAUTION: The installation of cross connection control devices will require additional measures to control heat expansion. The OWNER / OCCUPANT is responsible for the inspection, repair, and
maintenance of water heating equipment. Utilities Kingston requires that adequate premises protection is in place to ensure the safety of drinking water provided to our customers. The OWNER /
OCCUPANT is responsible for ensuring adequate zone protection is in place to ensure the safety of drinking water within the building / facility.
Location
Equipment Connected to or Serving
Existing Device Type / Serial number
Device Upgrade Recommended by Tester
MINOR MODERATE SEVERE
Hazard Level
Acceptable Protection in Place per City
of Kingston By-Law No. 2006-122?
YES - NOTE: If Yes, test reports must be submitted for devices used for
premises protection.
NO
Service
Connection
Cross
Connection
Meter Number
Device Required for:
Premises
Protection
Zone
Protection
Fire System
Connection
Connection Number
Fixture
Protection
Location
Equipment Connected to or Serving
Existing Device Type / Serial number
Device Upgrade Recommended by Tester
MINOR MODERATE SEVERE
Hazard Level
Acceptable Protection in Place per City
of Kingston By-Law No. 2006-122?
YES - NOTE: If Yes, test reports must be submitted for devices used for
premises protection.
NO
Service
Connection
Cross
Connection
Meter Number
Device Required for:
Premises
Protection
Zone
Protection
Fire System
Connection
Connection Number
Fixture
Protection
Location
Equipment Connected to or Serving
Existing Device Type / Serial number
Device Upgrade Recommended by Tester
MINOR MODERATE SEVEREHazard Level
Acceptable Protection in Place per City
of Kingston By-Law No. 2006-122?
YES - NOTE: If Yes, test reports must be submitted for devices used for
premises protection.
NO
Service
Connection
Cross
Connection
Meter number
Device Required
for:
Premises
Protection
Zone
Protection
Fire System
Connection
Connection Number
Fixture
Protection
I certify that I have competed this cross connection survey in accordance with the Utilities Kingston Cross Connection Control Program and in accordance with CSA
B64 standard and that the information provided is true and accurate.
DateCertified Tester SignatureCertified Tester Name
UTILITIES KINGSTON - DRINKING WATER SYSTEMS - CROSS CONNECTION CONTROL SURVEY
VERSION DATE: OCTOBER 23, 2019
PAGE 2 OF 2
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Completed 7 June 2021

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