Region of Durham

This survey is for premise isolation only.

Results must be submitted within 90 days of notification by the Region of Durham.

"*" indicates required fields

Facility Information

Facility Name*

CCN Number*

Contact Name*

First Last

Address*

Street Address Address Line 2 City / Township State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Account Number

Owner Information

Same as facility information*

Yes

Contact Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Business Name

Phone*

Email*

Surveyor Information

Name of Certified Tester*

First Last

Tester Certification Number*

Phone*

Surveyor Email*

Business Name*

Business Address*

Street Address City State / Province / Region ZIP / Postal Code

General Survey Information

Survey Date*

MM slash DD slash YYYY

Type of Water Use*

Building Type*

Is there a fire protection system?*

Yes

Fire Service Connection

Location*

Meter Number

Hazard Level*

Moderate

High

Fire Device Status*

Existing Device

Device Needed to be Installed

Existing Fire Device Type*

Fire Device Serial Number*

Fire Device Size*

Fire Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Do you have a second fire connection?

Yes

Second Fire Connection

Location*

Meter Number

Hazard Level*

Moderate

High

Second Fire Device Status*

Existing Device

Device Needed to be Installed

Existing Fire Device Type*

Fire Device Serial Number*

Fire Device Size*

Second Fire Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Is Premise Isolation required for this facility*

Yes

Yes, with Isolation Protection as an alternative due to restrictions that prevent true Premise Isolation

Domestic/Irrigation Connections

Connection #1*

Domestic Connection

Irrigation Connection

Location*

Meter Number

Hazard Level*

Moderate

High

Device Status*

Existing Device

Device Needed to be Installed

Existing Device Type*

Device Serial Number*

Size*

Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Do you have a second connection?

Yes

Connection #2

Connection #2*

Domestic Connection

Irrigation Connection

Location*

Meter Number

Hazard Level*

Moderate

High

2nd Device Status*

Existing Device

Device Needed to be Installed

Existing Device #2 Type*

Device Serial Number*

Size*

Device #2 Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Do you have a third connection?

Yes

Connection #3

Connection #3*

Domestic Connection

Irrigation Connection

Location*

Meter Number

Hazard Level*

Moderate

High

3rd Device Status*

Existing Device

Device Needed to be Installed

Existing Device #3 Type*

Device Serial Number*

Size*

Device #3 Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Do you have a fourth connection?

Yes

Connection #4

Connection #4*

Domestic Connection

Irrigation Connection

Location*

Meter Number

Hazard Level*

Moderate

High

4th Device Status*

Existing Device

Device Needed to be Installed

Existing Device #4 Type*

Device Serial Number*

Size*

Device #4 Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Do you have a fifth connection?

Yes

Connection #5

Connection #5*

Domestic Connection

Irrigation Connection

Location*

Meter Number

Hazard Level*

Moderate

High

5th Device Status*

Existing Device

Device Needed to be Installed

Existing Device #5 Type*

Device Serial Number*

Size*

Device #5 Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Last passing test date

MM slash DD slash YYYY

Acceptable Protection in Place*

Yes

Surveyor Recommendations

Please provide suggested type/make/model/size or any corrective action needed.

Full Disclosure*

I agree

This form is intended to assist the Authorized Tester in carrying out a survey for Premise Isolation of potential cross connection situations. It is the responsibility of the owner or building occupier to bring to the attention of the Authorized Tester all water uses within the premises to permit inspection for potential cross connections and recommendation of corrective actions.

Owner/Tenant Signature*

Authorized Tester Signature*

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 the Region of Durham By-law 24-2018 and may be used for the enforcement and administration of the By-law and will be stored by the Region for such period of time which facilitates the enforcement and administration of the By-law. Completion of this form constitutes consent by the owner and Authorized Tester to these terms and uses, unless otherwise modified or revised in writing to the Commission of Works for the Region of Durham.

Durham Region strongly recommends that you obtain several quotes before selecting a contractor and does not endorse or provide warranty of any services or prices. Please also be advised that contractors operate independently from Durham Region. We recommend you check their references, insurance, discuss costs and obtain a Workplace Safety and Insurance Board clearance certificate before proceeding with any work.

Contractors & Testers

A Marco Plumbing Ltd.BSI Online2024-12-09T14:31:38+00:00