Appendix D AF Form 848.pdf

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Attached to
Potable Water Backflow Prevention Survey
Solicitation number
FA462625Q0017
Issued by

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HOST BASE NAME

INSTALLATION NAME

SURVEY of CROSS-CONNECTION CONTROL AND BACKFLOW PREVENTION DEVICES

AREA ID NO.

FACILITY ID NO.

HAZARD

(CONTAMINANT

OR

COMMENTS

DEVICE

CROSS CONNECTION

CROSS CONNECTION

ID NO.

DEVICE TYPE

POLLUTANT)

CODES

TYPE

REQUIRED.

INSTALLED

LOCATION NO.

SERIAL NO.

CROSS CONNECTION TYPE: BP - Back Pressure, BS - Back Siphonage, CROSS CONNECTION CODES: HB - Hose Bibb with Hose, CM - Chemical Make Up, BM - Boiler System Make Up, FS-Fire Sprinkler System DEVICE TYPES: RP- Reduced Pressure, DC - Double Check, DCDA - Double check Detector Assembly, PVB - Pressure Vacuum Breaker, AVB Atmospheric Vacuum Breaker, Air Gap

AF FORM 848, 20071017

8.2.1.3158.1.475346.466429

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