Group_V:_Annual_Inspection_Cross-Connection_Form_Data_Sample.docx
DOCX document 15 KB Posted
- Solicitation number
- RFP# 202525
- Issued by
- Miami-Dade County, Florida
About this file
The document is a standardized cross-connection annual inspection form from the City of Homestead, Florida, designed to capture detailed information about backflow prevention device inspections. The form requires comprehensive data collection including business name, account and meter numbers, contact information, device location, inspection date, device specifications (manufacturer, model, type, size), and testing details such as plumber/contractor license number, test kit used, method of testing, and pass/fail status. The form includes a certification statement highlighting potential legal consequences for submitting false or fraudulent information, specifically referencing City of Homestead Code and potential first-degree misdemeanor penalties under Florida Statutes 775.082 or 775.083.
The form is intrinsically linked to municipal water system safety protocols, focusing on documenting and verifying the proper installation and functionality of backflow prevention assemblies. The form provides a structured method for recording ten distinct backflow preventer device types, including air gap (AG), community water system (CWS), double check valve assembly (DC), pressure vacuum breaker assembly (PVB), and reduced-pressure principle assembly (RP), among others. The comprehensive nature of the form ensures thorough documentation of cross-connection control measures, which are critical for maintaining public water system integrity and preventing potential contamination risks.
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Text version
The following information should be on the new form:
1. Name of business:
1. Account number:
1. Meter number:
1. Contact name/phone:
1. Address/physical location of business:
1. Location of the device:
1. Date of inspection:
1. Serial Number:
1. Manufacturer:
1. Model:
1. Type of backflow preventer device (please choose one of the following options):
10. AG = air gap;
10. CWS = community water system;
10. DC = double check valve assembly;
10. DCDA = double check detector assembly;
10. DuC = dual check device;
10. PVB = pressure vacuum breaker assembly;
10. PWS = public water system;
10. RP = reduced-pressure principle assembly;
10. RPDA = reduced-pressure principle detector assembly.
1. Size:
1. Name of plumber or contractor:
1. Plumber/contractor license number:
1. Test kit used:
1. Method of testing:
1. Pass/fail:
1. Repairs (if failed):
1. Final test pass/fail:
I Certify the above test is accurate and true, to the best of my ability. I also understand that under City of Homestead Code, the penalty for submitting false or fraudulent is a first-degree misdemeanor according to F.S., §§ 775.082 or 775.083.
I understand that improperly completed reports will not be accepted.
I certify the backflow prevention assembly is properly installed.
Signature Print Name Date
File details come from the government source that posted it. Updated .