BY-LAW 2007-
A By-law to regulate cross connections and backflow
prevention in private plumbing systems as required to protect the Town of
WHEREAS pursuant to section 11(3) and (11) of the Municipal Act,
S.O. 2001, as amended (hereinafter referred to as the “Municipal Act”) the Corporation of the Town of
AND WHEREAS the Town is deemed to be the “water purveyor” as defined by Part I of the Ontario Building Code;
AND WHEREAS pursuant to section 20(1) of the Safe Drinking Water Act, S.O. 2002, C.32, as amended, (hereinafter referred to as the “Safe Drinking Water Act”) it is an offence to cause or permit anything to enter a drinking-water system if it could result in, a drinking-water health hazard, a contravention of a prescribed standard or the interference with the normal operation of the system;
AND WHEREAS s. 11(1) of the Safe Drinking Water Act requires every owner of a municipal drinking water system, amongst other things, to ensure that all water provided by the system to the point where the system is connected to a user’s plumbing system meets the requirements of the prescribed drinking-water quality standards;
AND WHEREAS Part 7 of the Ontario Building Code requires potable water systems to be protected from contamination;
AND WHEREAS pursuant to s. 11(2) paragraph 6 of the Municipal Act a municipality may pass a by-law for purposes related to the health, safety and well-being of the inhabitants of persons;
AND WHEREAS contamination of the Town’s drinking-water supply can arise as a result
of a backflow incident from a private plumbing system which is attached to the
Town’s municipal drinking-water system;
AND WHEREAS the contamination of the municipal drinking-water system can have an
adverse impact on the health, safety and well-being of the users of the Town’s
drinking water;
AND WHEREAS, the Town desires to protect the health, safety and well-being of the inhabitants of the Town by passing a By-law to put mechanisms in place so as not to permit the discharging of a contaminating substance into the municipal drinking-water system for which the Town is responsible;
AND WHEREAS sections 446(1) and (3) of the Municipal
Act authorizes a
municipality by by-law to require, in default of a required matter or thing
being done, that the work may be done by the municipality at the expense of the
person required to do it and the costs may be added to the tax rolls and
collected in the same manner as taxes.
NOW
THEREFORE THE COUNCIL OF THE TOWN OF
1 DEFINITIONS
1.0 For the purposes of this By-law:
“ASSE” means the American Society of Sanitary Engineering;
“AWWA” means the American Water Works Association;
“Authorized Functions List” means the list of functions and the persons with the required qualifications authorized to carry out such functions as set out in Schedule “A” of this By-Law;
“auxiliary water supply” means any water source or system, other than the Town’s drinking water , that may be available in a building or structure on any property;
“backflow” means the flowing back of or reversal of the normal direction of flow of water, as defined by the Ontario Building Code, as amended ;
“backflow preventer ” means a device
that prevents backflow in a
water distribution system, as defined by the Ontario Building Code;
“back siphonage” means a backflow caused by negative pressure in the municipal water distribution system, as defined by the Ontario Building Code;
“building” shall have the same meaning as set out in the Building Code Act;
“Building Code Act” means the Building Code Act, S.O. 1992, c. 23, as amended, or any successor thereof;
“certified tester” means a person who is certified as a tester of backflow preventers;
“cross-connection” means any actual or potential connection between a potable water system and any source of pollution or contamination and includes any by-pass, jumper connection, removable section of pipe, swivel or changeover device and any other temporary or permanent connecting arrangement through which backflow may occur;
“Cross-Connection Survey Form” means the form attached as Schedule “B” of this By-Law;
“CSA Standard” means the document entitled CAN/CSA-B64.10-01 CAN/CSA-B64.10.1-01 & Amendments - Manual for the Selection and Installation of Backflow Prevention Devices / Manual for the Maintenance and Field Testing of Backflow Prevention Devices published in 2001 by the Canadian Standards Association, or such later edition as referenced by the Ontario Building Code;
“Director
of Operations” shall mean the person designated as the Director of
Operations for the Town of
“drinking water” means drinking water as defined in section 2(1) of the Safe Drinking Water Act as follows:
(a) water intended for human consumption, or
(b) water that is required by an Act, regulation, order, municipal by-law or other document issued under the authority of an Act,
i. to be potable, or
ii. to meet or exceed the requirements of the prescribed drinking-water quality standards
“drinking-water system” means drinking-water system as defined in section 2(1) of the Safe Drinking Water Act as follows:
means a system of works, excluding plumbing, that is established for the purpose of providing users of the system with drinking water which includes:
(a) any thing used for the collection, production, treatment, storage, supply or distribution of water,
(b) any thing related to the management of residue from the treatment process or the management of the discharge of a substance into the natural environment from the treatment system; and
(c) a well or intake that serves as the source of entry point of raw water supply for the system.
“Fire service main” as defined by the Ontario Building Code, means a pipe and its appurtenances that are
connected to a source of water and that are located on a property,
a) between the source of water and the base of
the riser of a water-based fire protection system,
b) between the source of water and inlets to
foam making systems,
c) between the source of water and the base
elbow of private hydrants or monitor nozzles,
d) as fire pump suction and discharge piping
not within a building, or
e) beginning at the inlet side of the check
valve on a gravity or pressure tank.
“minor hazard” means any cross-connection or potential cross-connection that constitutes only a nuisance, with no possibility of any health hazard, and which is identified as a minor hazard connection by the CSA Standards;
“moderate hazard” means any minor hazard that has a low probability of becoming a severe hazard, and which is identified as a moderate hazard connection by the CSA Standards;
“municipal drinking-water system” means municipal drinking-water system as defined by section 2(1) of the Safe Drinking Water Act as follows:
a drinking-water system or part of a drinking-water system,
(a) that is owned by a municipality or by a municipal service board established under s. 195 of the Municipal Act, 2001,
(b) that is owned by a corporation established under section 203 of the Municipal Act, 2001,
(c) from which a municipality obtains or will obtain water under the terms of a contract between the municipality and the owner of the system, or
(d) that is in a prescribed class;
“
“
“owner” means any person, firm or corporation having control over property to which this By-law applies and includes the owner registered on the title of the property and any occupant of any building or structure located on such property;
“plumbing” means plumbing as defined by the Safe Drinking Water Act as follows:
a system of works,
(a) that comprise a “water system” for the purposes of the definition of the Building Code Act, 1992, other than equipment installed in plumbing to treat water, and
(b) that are connected to a drinking-water system;
“potable water” means water that is safe for human consumption and that complies with section 10 of the Safe Drinking Water Act;
“potable water system” means the plumbing that conveys potable water;
“premise isolation” means isolation of the water located within a building or structure from the Town’s water supply;
"professional engineer" means a
person who holds a licence or a temporary licence issued under the Professional Engineers Act, R.S.O. 1990,
c.P. 28, as amended;
“residential full flow-through fire
sprinkler/standpipe system” means an assembly of pipes and fittings installed in the residential
portions of a building containing one or two dwelling units that conveys water
from the water service pipe to outlets in the sprinkler and standpipe systems
and is fully integrated into the potable water system to ensure a regular flow
of water through all parts of the sprinkler and standpipe systems, as defined
by Part I of the Ontario Building Code;.
“severe hazard” means any cross-connection or potential cross-connection involving any substance that could be a danger to health and which is identified as a severe hazard connection by the CSA Standards;
“source
isolation” means isolation of the water located within or having flowed
through a source or potential source of contamination within a building or
structure including a device, machine, water system or the like, from any
potable water system;
“structure” means anything constructed or built permanently or temporarily which is provided with a source of potable water;
“Test Report” means a report in the form set out as Schedule “C” of this By-law;
“Test Tag” means a tag in the form set out as Schedule “D” of this By-law;
“Town” means the Corporation of the
Town of
“water meter” means the water meter installed within a premises to record the amount of water supplied to such premises by the Town through the municipal drinking-water system;
“zone isolation” means the isolation of the water located within an area of a building or structure from any potable water system located within such building or structure.
2 APPLICATION OF BY-LAW
2.0 This By-law applies to all property within the Town, except buildings or structures of residential occupancies where each dwelling unit is individually serviced from the municipal drinking-water system through a single connection less than 50mm diameter.
2.1 Notwithstanding section 2.0 of this By-law, this By-law applies to plumbing in residential occupancies having connections to the municipal drinking-water system and
2.1.1 any auxiliary water supply, or
2.1.2 a lawn sprinkler system, or
2.1.3 a fire protection system, except for a residential full flow-through fire sprinkler/standpipe system.
3 CROSS-CONNECTION PROHIBITED – OWNER’S RESPONSIBILITY
3.0 No person or owner shall connect, cause to be connected, or allow to remain connected to the Town’s municipal drinking-water system or any other potable water system any plumbing, piping, fixture, fitting, container, appliance, vehicle, machine or the like in a manner which may under any circumstance allow water, waste water or any other liquid, chemical or substance to enter such municipal drinking-water system or potable water system.
3.1 No person or owner shall connect, cause to be connected, or allow to remain connected any auxiliary water supply or private well to a plumbing system which is supplied by the Town’s municipal drinking-water system.
4 PERSONS PERMITTED TO CARRY OUT WORK
4.0 Only those persons with the required qualifications listed in the Authorized Functions List attached as Schedule “A” shall carry out the corresponding functions set out in therein.
4.1 In order to perform Cross-Connection Surveys and testing of backflow preventers required pursuant to this By-law, the persons listed in the Authorized Functions List attached as Schedule “A” who are permitted to perform the survey or testing shall also have and submit proof of the following qualifications in a form satisfactory to the Town:
4.1.1 A certificate from an accredited organization or association issued in accordance with the requirements set by the ASSE or AWWA, designating the person as a “Certified Backflow Prevention Assembly Tester” which has been issued or renewed within five years prior to date of the submission of the Cross Connection Survey or Test Report; and
4.1.2 A current calibration certificate for the test equipment issued within the twelve months prior to date of submission of a Test Report.
5
APPLICATION OF CSA STANDARD
5.0 Except as otherwise set out in this By-law, the maintenance and field testing of backflow preventers required pursuant to this By-law shall be undertaken in accordance with the CSA Standard.
5.1
Wherever the CSA
Standard and this By-law are in conflict, the provisions of this By-law shall prevail.
6 CROSS-CONNECTION SURVEY REQUIRED
6.0 Every three years or as otherwise required by the Town, every owner of a building or structure to which this By-law applies shall cause a survey to be undertaken and carried out of all plumbing in each building or structure in accordance with the following:
6.0.1 the owner shall ensure that each survey conducted is carried out on the prescribed Cross-Connection Survey Form and is undertaken and completed by a person permitted to do so pursuant to the Authorized Functions List; and
6.0.2 the owner shall ensure that the completed Cross-Connection Survey Form is provided to the Director of Operations within 14 days of the survey being conducted.
6.1 Where a source isolation backflow preventer has been installed in equipment by the manufacturer of the equipment, the owner is required to have the cross-connection reviewed by a person permitted to do so pursuant to the Authorized Functions List to determine if the backflow preventer complies with the requirements of the Ontario Building Code and the CSA Standard. These cross-connections shall be identified on the Cross-Connection Survey Form.
6.2 When a new connection to the municipal drinking-water system is made, the owner shall complete and submit a survey prior to the plumbing being put into use.
6.3 Where a modification to plumbing, equipment or a process has been made after the submission of a survey as required by this by-law, the owner shall complete and resubmit a new survey to the Town prior to the modified plumbing being put into use.
7 INSTALLATION OF BACKFLOW PREVENTERS
7.0 Every person installing a backflow preventer or causing a backflow preventer to be installed or replaced shall ensure that:
7.0.1 such device is installed in accordance with good engineering practices and the requirements of the Building Code Act and the Ontario Building Code;
7.0.2 a building permit is obtained in accordance with the provisions of the Building Code Act;
7.1 Every owner of property upon which a backflow preventer is installed shall ensure that such device is in proper working order at all times.
8 TESTING OF DEVICES
8.0 Every owner who has a backflow preventer installed on his or her property shall ensure that:
8.0.1 such device is tested by a certified tester when it is first installed and annually thereafter or when requested by the Town, and also when it is cleaned, repaired, overhauled or relocated;
8.0.2
when such device is tested, that a Test Report of
such test is completed by a person permitted to do so pursuant to the Authorized
Functions List on a form approved by the Town;
8.0.3
the Test Report
is submitted to the Director of Operations within 14 days of the test
being conducted by the certified tester;
and
8.0.4 in the event that such device is malfunctioning or otherwise not in proper working order, cause the device to be repaired or replaced forthwith.
8.1 Every person who tests a backflow preventer shall carry out such testing in accordance with this By-law and the CSA Standard.
8.2 In addition to the testing methods set out in section 6 of the CSA Standard, test procedures established by the ASSE or AWWA for testing backflow preventers may be employed.
8.3 Every person who tests a backflow preventer shall:
8.3.1 within 14 days of carrying out such test, provide a legible Test Report to the Director of Operations in respect of such test;
8.3.2 upon completing such test, complete and affix a Test Tag to the device or immediately adjacent to the device on the piping connected thereto; and
8.3.3 upon finding that such device is malfunctioning or otherwise not in proper working order, immediately notify the owner of the premises and the Town of such condition.
9 MAINTENANCE OF FIRE SERVICE MAINS
9.0 Where a private fire hydrant or yard hydrant is connected to a fire service main that is supplied by the municipal drinking-water system, the owner shall cause the hydrant to be inspected annually as required by s. 6.6.5.1 of the Ontario Fire Code and shall provide the Town with a copy of the record of hydrant operation as required to be kept in accordance with s. 6.6.5.8 of the Ontario Fire Code.
10 ADMINSTRATION AND ENFORCEMENT
10.0
The Director of
10.1 Everyone who contravenes any of the provisions of this By-law is guilty of an offence and upon conviction is liable to a maximum fine as established pursuant to the provisions of the Provincial Offences Act, R.S.O. 1990, c.P. 33, as amended.
10.2 Where the requirements of this By-law are not met or a condition exists on any property that may allow contamination of the Town’s municipal drinking-water system or Town’s water supply or the contamination of any other potable water system on such property, including any residential building or structure, the Town may:
10.2.1 issue and serve an Order to Comply on the owner of the property requiring the owner to comply with the requirements of the By-law and/or to eliminate the condition which may allow contamination and in so doing may prescribe the time period for compliance with such Order; or
10.2.2 If a condition exists on a property which may result in the contamination of the Town’s municipal drinking-water system or the Town’s water supply, the Town may, in addition to issuing an Order to Comply, shut off the water supply to the property or any portion thereof until the condition is eliminated to the satisfaction of the Town.
10.3 Service of an Order to Comply shall be made by personal service or by prepaid registered mail to the address of the owner shown on the last revised assessment roll. Where service is made by registered mail, it shall be deemed to have been received by the owner on the fifth day after the date of mailing.
10.4 Wherever this By-law directs or requires any work or thing to be done, in default of it being done by the person directed to do it, such work may be done by the Town or its agents at the expense of the person and the Town may recover all expenses incurred in doing the work by action or by adding the costs to the tax roll and collecting them in the same manner as taxes.
10.5 In addition to any other provision of this By-law, the Town may at any time issue an Order to an owner to conduct tests, provide reports and undertake any other measures required for the elimination of a cross-connection and the prevention of backflow.
11 GENERAL PROVISIONS
11.0 Where a timeframe is set out in this By-law for carrying out any action, the Town may extend the time for compliance beyond the established timeframe provided such extension is required and is acceptable to the Town.
11.1 Schedule “A” through “D” inclusive and the CSA Standard shall form part of this By-law.
11.2 If a court of competent jurisdiction declares any section or part of this By-law invalid or unenforceable, it is the intention of Council that the remainder of the By-law shall continue to be in force.
11.3 This By-law comes into force and effect on the date of its passing and enactment.
12 DATE OF COMPLIANCE
12.0 Completion of the first cross-connection survey and testing of backflow preventers and assemblies shall occur prior to the date set out below for the degree of hazard:
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Degree of Hazard According To CAN/CSA-B64.10-01 |
Compliance Date |
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Severe |
one year from passage of the By-law |
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Moderate and Minor |
three years from passage of the
By-law |
READ A FIRST, SECOND AND THIRD TIME AND PASSED THIS
DAY OF , 2007
________________________________ _____________________________
SHEILA BIRRELL, TOWN CLERK FRANK SCARPITTI, MAYOR
Note: Schedule “A” - Authorized Function List
Schedule “B” – Cross-Connection Survey
Schedule “C” – Test Report, Reduced Pressure Principle Backflow Prevention Assembly
Schedule “D” – Test Report, Double Check Valve/Pressure Vacuum Breaker
Schedule “E” – Test Tag
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SCHEDULE "A" |
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Town of |
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By-law Number 2007 -xx |
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AUTHORIZED FUNCTIONS LIST |
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ITEM |
FUNCTION |
Professional
Engineer with Tester’s Certificate |
Certified
Engineering Technologist1 with Tester’s Certificate |
Licensed
Master Plumber with Tester’s Certificate |
Journeyman
Plumber2 with Tester’s Certificate |
Apprentice
Plumber3 with Tester’s Certificate |
Fire
System Sprinkler Fitter with Tester’s Certificate |
Lawn
Irrigation System Installer with Tester’s Certificate |
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1 |
Carry out Cross Connection Survey |
ü |
ü |
ü |
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2 |
Test Backflow Prevention Device |
ü |
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3 |
Items 1, 2, 3 & 4 above in Respect of Fire Protection
Systems |
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4 |
Items 3 & 4 above in Respect of Lawn Sprinkler System |
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Note:
Tester’s Certificate means “Certified Backflow Prevention
Assembly Tester” certificate obtained from an accredited organization or
association. |
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1 |
Required to be under the direction of a Professional
Engineer |
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2 |
Required to be employed by a Licensed Plumbing Contractor |
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3 |
Required to be employed by a Licensed Plumbing Contractor
and under the direct supervision of a Master Plumber or Journeyman Plumber |
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SCHEDULE “B” |
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CROSS-CONNECTION
SURVEY |
Date (YYYY/MM/DD): |
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Page # |
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Note:
Surveyor is required to submit copies of this report to the Town of |
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Building/Facility: |
Address: |
Owner: |
Report
Given to (Owner):
Signature of Surveyor: |
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Surveyor
Name: Occupation: Telephone
Number: Business
Address: |
Authorized
Function List Qualifications Submitted ¨ Submitted within
previous 12 Months, or ¨ Backflow Prevention
Device Tester certificate |
Town of ¨ Meter on Domestic Water
Service Serial Number: ¨ Meter on Fire
Protection System Service Serial Number: |
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Location
of Cross-Connection |
Existing
Protection Type |
Serial # (If Applicable) |
Date of
Last Test (If Applicable) |
Acceptable
Protection Yes/No |
Required
Upgrade |
Remarks |
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1 |
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2 |
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7 |
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9 |
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The Personal
information collected herein is subject to the Municipal Freedom of Information and Protection of Privacy Act. The information is collected under
the authority of Town of Markham By-law 2007- XXX and may be used for the
enforcement and administration of the By-law, and will be stored by the Town
for such period of time which facilitates the enforcement and administration
of the By-law. Completion of this form constitutes consent by the owner,
tester and/or surveyor to these terms and uses, unless otherwise modified or
revised in writing and delivered to the Director of |
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* DCVA/DCVAF |
- Double
Check Valve Assembly/Double Check Valve Assembly for Fire Protection |
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RP/RPF - Reduced Pressure
Principle/Reduced Pressure Principle for Fire Protection |
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* AVB |
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Atmospheric Vacuum Breaker |
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SCVAF - Single Valve for Fire
Protection |
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* PVB |
-
Pressure Vacuum Breaker |
AG -
Air Gap |
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HCVB |
- Hose
Connection Vacuum Breaker |
*LACV - Listed Alarm Check Valve |
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LFVB |
- Laboratory
Faucet Vacuum Breaker |
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RSCV - Resilient Seated Check Valve |
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* DCAP |
- Dual
Check Valve with Atmospheric Port |
N -
None |
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* DuC/DuCF |
- Dual
Check Valve/Dual Check Valve for Fire Protection |
* -
Building Permits required for installation of these devices |
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* DuCV |
- Dual
Check Valve with Intermediate Vent |
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SCHEDULE
“C” By-law Number 2007-xx |
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TEST
REPORT |
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Cross-Connection Control |
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Telephone: 905-477-7000 |
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Fax: 905-479-7772 |
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Email: waterworks@markham.ca |
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Note: Tester is required to
submit copies of this report to the Town of |
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Address Location
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Postal Code |
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Occupant |
Emergency Contact Person |
Telephone |
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Owner
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Telephone |
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Address of Owner
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Postal Code |
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Name of Certified Tester Occupation: |
Tester Certification Information: ¨ Submitted within previous 12
Months, or ¨ Backflow Prevention Device Tester
certificate |
Telephone |
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Business Name |
Business Address |
Postal Code |
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Make of TEST KIT |
Model Number |
Serial Number |
Date of Last calibration |
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Make of ASSEMBLY |
Model Number |
Serial Number |
Size |
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INSTALL DATE |
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MM |
DD |
Location of Assembly (ie. Building, room number, installed on what system) |
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Premise o Source o Zone o |
Device Tagged? Yes o No □o |
Antifreeze solution test meets the requirements of NFPA? Yes o No o |
Water Works Valve Lock Removed? Yes o No o |
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TYPE OF TEST Initial o Annual o Other o |
Date of Test |
YYYY |
MM |
DD |
SHUT OFF VALVE NO. 2 Leaked o Closed Tight o |
Line pressure at time of test ____Psi __kPa |
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TEST |
Differential
Pressure Relief Value |
Check Valve No. 1 |
Check Valve No. 2 |
TEST RESULTS Passed o Failed o |
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o Failed to Open o Opened at _____ Psi _____ kPa |
Leaked o Closed Tight o |
Leaked o Closed Tight o |
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Pressure differential across ____kPa First check valve (no flow) _____Psi |
Pressure differential across ___kPa First check valve (no flow) _____Psi |
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IF THE ASSEMBLY FAILS THE INITIAL TEST FOR ANY REASON, COMPLETE THIS SECTION AND NOTE REPAIR BELOW:
Reason for Failure (if apparent)
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REPAIRS |
Differential Pressure Relief Value |
Check Valve No. 1 |
Check Valve No. 2 |
Shut Off Valve No. 2 |
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CLEANED REPLACED |
CLEANED REPLACED |
CLEANED REPLACED |
CLEANED REPLACED |
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o |
Disc Upper |
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Disc |
o |
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Disc |
o |
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Disc |
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Disc Lower |
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Spring |
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Spring |
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Seat |
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Spring |
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Guide |
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Guide |
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Other(describe) |
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Diaphragm Large |
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Pin Retainer |
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Pin Retainer |
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Upper |
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Hinged Pin |
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Hinged Pin |
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Lower |
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Seat |
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Seat |
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Spacer Lower |
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Diaphragm |
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Diaphragm |
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Seat |
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Other (describe) |
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Other (describe) |
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Other (describe) |
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DATE OF RE-TEST |
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YEAR MONTH DAY |
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/ / |
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RE-TEST |
o Failed to Open o Opened at ____ Psi ____kPa |
Leaked □ Closed Tight □ |
Leaked □ Closed Tight □ |
RE-TEST RESULTS Passed o Failed o |
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Pressure differential across___ kPa First check valve (no flow)_____Psi |
Pressure differential across___ kPa First check valve (no flow)_____Psi |
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Remarks:__________________________________________________________________________________________________________________ |
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__________________________________________________________________________________________________________________________ |
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OFFICE USE ONLY |
I hereby declare that the information provided herein is true and certify that I have tested the above assembly in accordance to the Town of Markham By-Law 2007-xx as amended and CAN/CSA-B64.10-01 |
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Signature of Certified Tester |
Date YY MM DD |
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WHITE – Markham |
YELLOW – Tester |
PINK – Occupant or Owner |
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The personal information collected herein is subject
to the Municipal Freedom of Information
and Protection of Privacy Act. The
information is collected under the authority of Town of |
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SCHEDULE
“D” |
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TEST
REPORT Pressure Vacuum Breaker |
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Cross-Connection Control |
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Telephone: 905-477-7000 |
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Fax: 905-479-7772 |
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Email: waterworks@markham.ca |
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Note: Tester is required to
submit copies of this report to the Town of |
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Address Location
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Postal Code |
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Occupant |
Emergency Contact Person |
Telephone |
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Owner
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Telephone |
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Address of Owner
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Postal Code |
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Name of Certified Tester |
Tester Certification Information: ¨ Submitted within previous 12
Months, or ¨ Backflow Prevention Device Tester certificate |
Telephone |
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Business Name |
Business Address |
Postal Code |
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Make of TEST KIT |
Model Number |
Serial Number |
Date of Last Calibration |
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Make of ASSEMBLY |
Model Number |
Serial Number |
Size |
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INSTALL DATE |
YY |
MM |
DD |
Location of Assembly (ie. Building, room number, installed on what system) |
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Premise o Source o Zone o |
Device Tagged? Yes o No o |
Antifreeze solution test meets the requirements of NFPA-? Yes o No o |
Waterworks Valve Lock Removed? Yes o No o |
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TYPE OF TEST Initial o Annual o Other o |
Date of Test |
YYYY |
MM |
DD |
SHUT OFF VALVE NO. 2 Leaked o Closed Tight o Line pressure at time of test _____Psi _____kPa |
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TEST |
Check Valve No 1 |
Check Valve No 2 |
Pressure Vacuum Breaker |
Test Results |
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With Flow |
Against Flow |
With Flow |
Against Flow |
Air in Valve |
Chck Valve |
Passed o |
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o Leaked |
o Leaked |
o Leaked |
o Leaked |
o Failed to Open |
o Leaked |
Failed o |
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o Closed Tight |
o Closed Tight |
o Closed Tight |
o Closed Tight |
o Opened at |
o Closed tight Pressure Drop kPa |
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Sight Tube Test |
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Passed o |
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Pressure Drop Kpa |
Pressure Drop Kpa |
Kpai |
across check Psi |
Failed o |
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Across Check Psi |
Across Check Psi |
Psi |
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IF THE ASSEMBLY FAILS THE INITIAL TEST FOR ANY REASON, COMPLETE THIS SECTION AND NOTE REPAIR BELOW:
Reason for Failure (if apparent)
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REPAIRS |
DOUBLE CHECK VLV ASSEMBLY |
Pressure Vacuum Breaker |
Date of Re-test |
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Check Valve No. 1 |
Check Valve No. 2 |
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o Disc o |
o Disc o |
o Disc o |
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o Spring o |
o Spring o |
o Spring o |
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o Guide o |
o Guide o |
o Guide o |
/ / |
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o Pin Retainer o |
o Pin Retainer o |
o Pin Retainer o |
YY MM DD |
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o Hinged Pin o |
o Hinged Pin o |
o Hinged Pin o |
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o Seat o |
o Seat o |
o Seat o |
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o Diaphragm o |
o Diaphragm o |
o Diaphragm o |
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o Other (describe) o |
o Other (describe) o |
o Other (describe) o |
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RE-TEST |
With Flow |
Against Flow |
With Flow |
Against Flow |
Air inlet Valve |
Check Valve |
Test Results |
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o Leaked |
o Leaked |
o Leaked |
o Leaked |
o Failed to Open |
o Leaked |
Passed o |
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o Closed Tight |
o Closed Tight |
o Closed Tight |
o Closed Tight |
o Opened at |
o Closed tight |
Failed o |
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Pressure Drop kPa |
Pressure Drop kPa |
Psi |
Pressure drop kPa |
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Across check Psi |
Across check Psi |
Psi |
Across check
Psi |
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Remarks:__________________________________________________________________________________________________________________ |
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__________________________________________________________________________________________________________________________ |
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OFFICE USE ONLY |
I hereby declare that the information provided herein is
true and I certify that I have tested the above assembly in accordance to the
Town of |
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Signature of Certified Tester |
Date YY MM DD |
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WHITE – Markham |
YELLOW – Tester |
PINK – Occupant or Owner |
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The personal information collected herein is subject
to the Municipal Freedom of Information
and Protection of Privacy Act. The
information is collected under the authority of Town of Markham By-law 2007 –
XXX and may be used for the enforcement and administration of the By-law, and
will be stored by the Town for such period of time which facilitates the
enforcement and administration of the By-law.
Completion of this form constitutes consent by the owner, tester
and/or surveyor to these terms and uses, unless otherwise modified or revised
in writing and delivered to the Director of |
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SCHEDULE "E"
Town of
By-law
Number 2007-XX
TEST
TAG
Front of tag
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Town of Cross-Connection Control (905) 477-7000 |
DATE INSTALLED |
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BACKFLOW PREVENTION
ASSEMBLY TAG |
YY YY |
MM |
DD |
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ADDRESS |
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TYPE OF ASSEMBLY oRP oDCVA oPVB |
MANUFACTURER |
SIZE |
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MODEL NUMBER: |
SERIAL NUMBER |
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LOCATION: |
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DO NOT REMOVE |
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Reverse side
of tag
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TEST DATE |
TESTER’S COMPANY |
TESTER’S NO. |
TESTER’S INITIALS |
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YY |
MM |
DD |
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DO NOT REMOVE |
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