TE-4_CCC Hazard Survey Report.pdf

PDF 177 KB Posted

Attached to
Cross Connection Survey Federal contract opportunity
Solicitation number
PANMCC-21-P-0000007455
Issued by
Department of the Army Materiel Command Mission and Installation Contracting Command Joint Base Lewis-McChord

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Other files for this federal contract opportunity

Other files attached to Cross Connection Survey, newest first.
File Type Posted
PWS_Cross-Connection Survey 01.05.2021.docx DOCX document
TE-2_Deliverables_12.22.2020.docx DOCX document
TE-3_Irrigation BFP (Lewis-Main).xlsx XLSX spreadsheet
TE-1_Performance Requirements Summary.docx DOCX document

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Cross-Connection Control Hazard Survey Report Non-Residential Customers

Survey date: ____________

Customer Information

Premises name: ___________________________________Telephone: ___________________

Address: ______________________________________________________ZIP: ___________

Contact person: _____________________________________Title: ______________________

Description of premises: _________________________________________________________

Description of water use: ________________________________________________________

Water Service and Backflow Prevention Assembly (BPA) Size/Type

Service Type

Service Size

Meter Size

BPA

Size

BPA

Type

Irrigation

Cross-Connection Control Specialist (CCS) Information

Name: ______________________________________ Telephone: ____________________

Company name: ________________________________________________________________

Address: ________________________________________________________ZIP: __________

DOH CCS Certification #: _____________________ Year certified: _________________

Cross Connection Control Survey Report (Continued)

Survey Results

Note: The CCS’s survey shall include an inspection of the premises isolation assembly to verify that it is installed correctly and is a currently listed DOH-approved assembly.

Item Location & Description of Cross Connection

Backflow Prevention Provided/Required

Attach additional sheets if needed.

Surveyor's Comments

Cross-Connection Control Survey Report (Continued)

Surveyor's Recommendations

I certify that this cross-connection hazard survey accurately reflects the overall risk posed by the customer's plumbing system to the Purveyor's distribution system. Based on the above survey, I certify that:

1. I found the following type(s) of premises isolation backflow preventer(s):

Air Gap ____ RPBA/RPDA ____ DCVA/DCDA _____ None ____.

2. The existing backflow preventer(s) is/are properly installed.

Yes ____ No ____ N/A ____.

3. The existing backflow preventer(s) is/are commensurate with the degree of hazard:.

Yes ____ No ____ N/A ____.

4. Since no backflow preventer was installed for premises isolation, the premises owner should install a premises isolation backflow preventer of the following type:

Air Gap ____ RPBA/RPDA ____ DCVA/DCDA ____ N/A ____.

5. The premises owner should replace the existing premises isolation backflow preventer(s) with the following:

Air Gap ____ RPBA/RPDA ____ DCVA/DCDA ____ N/A ____.

The completed survey report shall be first signed by the CCS conducting the survey, and then counter-signed by the owner of the premises or the owner’s authorized agent.

CCS Signature: _________________________________Date: ______________

As the Owner of the Premises (or Owner’s authorized agent), I certify that I have received a copy of this completed Cross-Connection Control Hazard Survey Report.

Signature: _______________________________________Date: ____________

Note: Customers and regulatory agencies should be aware that the Purveyor's requirement for this cross-connection hazard survey and/or for the installation of a specific backflow prevention assembly on a service pipe do not constitute an approval of the customer's plumbing system, compliance of the customer's plumbing system with the Uniform Plumbing Code or an assurance of the absence of cross connections in the customer’s plumbing system.

Survey date:
Premises name:
Telephone:
Address:
ZIP:
Contact person:
Title:
Description of premises:
Description of water use:
Service SizeDomestic:
Meter SizeDomestic:
BPA SizeDomestic:
BPA TypeDomestic:
Service SizeFire:
Meter SizeFire:
BPA SizeFire:
BPA TypeFire:
Service SizeIrrigation:
Meter SizeIrrigation:
BPA SizeIrrigation:
BPA TypeIrrigation:
Service SizeOther:
Meter SizeOther:
BPA SizeOther:
BPA TypeOther:
Name:
Telephone_2:
Company name:
Address_2:
ZIP_2:
DOH CCS Certification:
Year certified:
ItemRow1:
Location Description of Cross ConnectionRow1:
Backflow Prevention ProvidedRequiredRow1:
ItemRow2:
Location Description of Cross ConnectionRow2:
Backflow Prevention ProvidedRequiredRow2:
ItemRow3:
Location Description of Cross ConnectionRow3:
Backflow Prevention ProvidedRequiredRow3:
ItemRow4:
Location Description of Cross ConnectionRow4:
Backflow Prevention ProvidedRequiredRow4:
ItemRow5:
Location Description of Cross ConnectionRow5:
Backflow Prevention ProvidedRequiredRow5:
ItemRow6:
Location Description of Cross ConnectionRow6:
Backflow Prevention ProvidedRequiredRow6:
ItemRow7:
Location Description of Cross ConnectionRow7:
Backflow Prevention ProvidedRequiredRow7:
ItemRow8:
Location Description of Cross ConnectionRow8:
Backflow Prevention ProvidedRequiredRow8:
ItemRow9:
Location Description of Cross ConnectionRow9:
Backflow Prevention ProvidedRequiredRow9:
ItemRow10:
Location Description of Cross ConnectionRow10:
Backflow Prevention ProvidedRequiredRow10:
ItemRow11:
Location Description of Cross ConnectionRow11:
Backflow Prevention ProvidedRequiredRow11:
ItemRow12:
Location Description of Cross ConnectionRow12:
Backflow Prevention ProvidedRequiredRow12:
ItemRow13:
Location Description of Cross ConnectionRow13:
Backflow Prevention ProvidedRequiredRow13:
ItemRow14:
Location Description of Cross ConnectionRow14:
Backflow Prevention ProvidedRequiredRow14:
ItemRow15:
Location Description of Cross ConnectionRow15:
Backflow Prevention ProvidedRequiredRow15:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
Air Gap:
RPBARPDA:
DCVADCDA:
None:
Yes:
No:
NA:
Yes_2:
No_2:
NA_2:
Air Gap_2:
RPBARPDA_2:
DCVADCDA_2:
NA_3:
Air Gap_3:
RPBARPDA_3:
DCVADCDA_3:
NA_4:
Date:
Date_2:
connections in the customers plumbing system:

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