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OxfordBSI Online2024-07-09T13:59:04+00:00

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Cross Connection Survey | Survey must be completed and submitted by a qualified contractor.

"*" indicates required fields

General Survey Information

CCN*

Property Contact

First Last

Property Occupant*

Phone*

Date of Survey*

MM slash DD slash YYYY

Service Address*

Street Address City Province Postal Code

Mailing Name

Mailing Address*

Street Address City Province Postal Code

Is there a Domestic Cold Water Service*

Yes

No

Domestic Water Connection

Hazard Level*

Minor (No Premise Containment)

Moderate (Minimum DCVA level of protection)

Severe (Minimum RP level of protection)

Location*

Meter Number*

Is there Acceptable Protection in Place?*

Yes

No

Surveyor Recommendations

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

Date of Last Test

MM slash DD slash YYYY

Device Type*

Device Serial Number*

Size*

Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a parallel backflow device?*

Yes

No

Parallel Backflow Device Information

Device Type*

Date of Last Test

MM slash DD slash YYYY

Device Serial Number*

Size*

Parallel Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a 2nd Domestic Cold Water Service?

Yes

No

Domestic Cold Water Service #2 Connection

Hazard Level*

Minor (No Premise Containment)

Moderate (Minimum DCVA level of protection)

Severe (Minimum RP level of protection)

Location*

Bypass Around Water Service

Meter Number*

Acceptable Protection in Place*

Yes

No

Surveyor Recommendations

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

Date of Last Test

MM slash DD slash YYYY

Device #2 Type*

Device Serial Number*

Size*

Device #2 Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a parallel backflow device on the 2nd Connection?*

Yes

No

2nd Connection Parallel Backflow Device Information

2nd Connection Device Type*

Date of Last Test

MM slash DD slash YYYY

Device Serial Number*

Size*

2nd Connection Parallel Backflow Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a Fire Suppression System*

Yes

No

Fire Service Connection

Class (if known)

Location (room)*

Chemical

Yes

No

Hazard Level (if known)

Minor

Moderate

Severe

Isolation*

Premise

Zone

Backflow Device Present*

Yes

No

Surveyor Recommendations

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

Date Last Tested

MM slash DD slash YYYY

Fire Device Type*

Fire Device Serial Number*

Fire Device Size*

Fire Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a detector Parallel Backflow Device on the fire system?*

Yes

No

Fire System Bypass Information

Fire System Parallel Backflow Device Type*

Date of Last Test

MM slash DD slash YYYY

Parallel Backflow Device Serial Number*

Size*

Fire System Parallel Backflow Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there an Irrigation System?*

Yes

No

Irrigation System Connection

Hazard Level*

Minor

Moderate

Severe

Is it metered?*

Yes

No

Meter Number*

Location*

Acceptable Protection in Place for Irrigation Device?*

Yes

No

Surveyor Recommendations

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

Date of Last Test

MM slash DD slash YYYY

Irrigation Device Type

Irrigation Device Serial Number*

Irrigation Device Size*

Irrigation Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a Parallel Backflow Device on the Irrigation System?*

Yes

No

Irrigation System Parallel Backflow Device Information

Irrigation System Parallel Backflow Device Type*

Date of Last Test

MM slash DD slash YYYY

Device Serial Number*

Size*

Irrigation System Parallel Backflow Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there an Auxiliary Water Source

Yes

No

Auxiliary Water Connection

Hazard Level*

Minor

Moderate

Severe

Location*

Meter Number*

Is the auxiliary connection connected to the municipal water supply?

Yes

No

Acceptable Protection in Place for Auxiliary Water Connection?*

Yes

No

Surveyor Recommendations

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

Date of Last Test

MM slash DD slash YYYY

Auxiliary Water Connection Device Type*

Auxiliary Water Connection Device Serial Number*

Auxiliary Water Connection Device Size*

Auxiliary Water Connection Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a Parallel Backflow Device on the auxiliary water connection?*

Yes

No

Auxiliary Water Connection Parallel Backflow Device Information

Auxiliary Water Connection Parallel Backflow Device Type*

Date of Last Test

MM slash DD slash YYYY

Device Serial Number*

Size*

Auxiliary Water Connection Parallel Backflow Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there Process Water Connection?

Yes

No

Process Water Connection

Location*

Hazard Level*

Minor

Moderate

Severe

Acceptable Protection in Place for Process Water Device?*

Yes

No

Surveyor Recommendations

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

Date of Last Test

MM slash DD slash YYYY

Process Water Device Type*

Process Water Device Serial Number*

Process Water Device Size*

Process Water Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Is there a Parallel Backflow Device on the process water connection?*

Yes

No

Process Water Connection Parallel Backflow Device Information

Process Water Connection Parallel Backflow Device Type*

Date of Last Test

MM slash DD slash YYYY

Parallel Backflow Device Serial Number*

Size*

Process Water Connection Parallel Backflow Device Make*

Ames*

Apollo*

Conbraco*

Febco*

Watts*

Wilkins*

Other Make and Model*

Are any of the following Present?

Is there a Trap Seal?

Yes

No

Location

Upstream of Backflow Device

Downstream of Backflow Device

Hose Bib with Threads?

Yes

No

Pressure Reducing Valve?

Yes

No

Location

Upstream of Backflow Device

Downstream of Backflow Device

Comments

Surveyor Information

Name of Certified Tester*

First Last

Tester Email

Phone

Business Name*

Testing Company Address

Street Address Address Line 2 City Province Postal Code

Consent*

I agree

I confirm that I have explained the above noted cross connections during this cross connection survey and have advised the Owner of the steps necessary to eliminate the above listed cross-connections and any other cross connections that may be found inside the property.

I understand there is a $30.00 + HST Survey Submission Fee which will be invoiced to me by Oxford County at the end of each calendar month.

Δ

Oxford County Testing Companies Registered with BSI

Adam’s Plumbing & PumpsBSI Online2023-12-07T20:11:19+00:00

Adam’s Plumbing & Pumps

Lynden | 1-888-858-3112
service@adamsplumbingandpumps.ca

Adaptive Mechanical IncBSI Online2024-02-05T14:22:11+00:00

Adaptive Mechanical Inc

Cambridge | 226-600-8146
johnc@adaptivemech.com

Atomic Plumbing and Heating Inc.BSI Online2024-02-23T17:38:28+00:00

Atomic Plumbing and Heating Inc.

519-496-5463 | Markdale
atomicplumbingservices@gmail.com

B.R.’s Plumbing and Heating IncBSI Online2024-02-08T15:15:54+00:00

B.R.’s Plumbing and Heating Inc

Tillsonburg | 519-688-5999
nancy@brsplumbingandheating.ca

Backflow Pro/Tessco PlumbingBSI Online2023-12-07T20:19:02+00:00

Backflow Pro/Tessco Plumbing

Brantford | 519-750-4244
jason@backflowpro.ca

Barrett Mechanical Inc.BSI Online2023-12-07T20:20:39+00:00

Barrett Mechanical Inc.

London | 519-652-7207
info@barrettmechanical.com

Besterd MechanicalBSI Online2023-12-11T18:53:07+00:00

Besterd Mechanical

London | 519-6728454
Lirving@besterd.ca

Blue Collar Plumbing IncBSI Online2024-02-23T17:37:50+00:00

Blue Collar Plumbing Inc

226-228-9406 | Woodstock
bluecollarplumbingservice@gmail.com

BMMB Construction Group IncBSI Online2024-01-19T15:00:59+00:00

BMMB Construction Group Inc

Ingersoll | 519-212-5922
info@bmmb.ca

Brenner Mechanical Inc.BSI Online2023-12-07T20:28:49+00:00

Brenner Mechanical Inc.

Waterloo | 519-746-0439
info@brenner.ca

Brisson & Massie Mechanical Inc.BSI Online2023-12-07T20:31:17+00:00

Brisson & Massie Mechanical Inc.

London | 519-668-2351
pbrisson@brissonmassie.com

Cimco RefrigerationBSI Online2023-12-07T20:43:24+00:00

Cimco Refrigeration

London | 519-439-1300
rhenshaw@toromont.com

CMS Custom Mechanical ServicesBSI Online2023-12-07T20:48:55+00:00

CMS Custom Mechanical Services

London | 519-318-2453
pam019@sympatico.ca

Copper Snake PlumbingBSI Online2023-12-07T20:49:31+00:00

Copper Snake Plumbing

London | 226-268-6435
coppersnakeplumbing@gmail.com

Culliton Inc.BSI Online2024-06-11T19:20:18+00:00

Culliton Inc.

Stratford | 519-271-1981
service@culliton.com

Curney Mechanical LtdBSI Online2024-01-03T13:56:47+00:00

Curney Mechanical Ltd

London | 519.453.1614
cathy@curney.ca

Dave Hurst Plumbing & Heating Inc.BSI Online2023-12-07T20:52:53+00:00

Dave Hurst Plumbing & Heating Inc.

Kitchener | 519-893-3464
dispatch@hurstplumbingheating.com

Drains R Us PlumbingBSI Online2024-01-03T13:51:40+00:00

Drains R Us Plumbing

Cambridge | 519-654-0007
info@drainsrusplumbing.ca

Due North MechanicalBSI Online2024-02-23T17:39:29+00:00

Due North Mechanical

226-988-8060 | Ayr
matt@duenorthmechanical.ca

EcoPure Plumbing IncBSI Online2024-06-11T19:19:50+00:00

EcoPure Plumbing Inc

London | 519-690-2434
info@ecopureplumbing.ca

EOS Mechanical Inc.BSI Online2024-04-29T11:56:47+00:00

EOS Mechanical Inc.

Concord | 647-621-6811
info@eosmechanical.ca

Freeman MechanicalBSI Online2024-07-11T12:28:25+00:00

Freeman Mechanical

Ingersoll | 519-535-9983
Scott@freemanmechanical.ca

George Forsyth Plumbing & HeatingBSI Online2024-06-03T17:40:11+00:00

George Forsyth Plumbing & Heating

Delhi | 519-688-8400
Darren@forsythplumbing.ca

Gowing Water Plumbing & Heating IncBSI Online2024-01-10T18:11:26+00:00

Gowing Water Plumbing & Heating Inc

Cambridge | 519-504-1255
alex@gowingwater.com

Hesselmans Plumbing & Heating Ltd.BSI Online2023-12-07T20:57:13+00:00

Hesselmans Plumbing & Heating Ltd.

London | 519-644-1317
joehesselmans@gmail.com

Hunter Plumbing, Heating & Excavating IncBSI Online2024-01-03T13:54:45+00:00

Hunter Plumbing, Heating & Excavating Inc

Princeton | 519-458-4488
info@hunterplumbing.ca

Kirwin PlumbingBSI Online2024-06-26T16:13:37+00:00

Kirwin Plumbing

Embro | 519-535-1659
benkirwin@kirwinplumbing.info

LEaC Shield Ltd.BSI Online2023-12-07T21:04:40+00:00

LEaC Shield Ltd.

London | 855-946-1783
adirc@leacshield.com

McGregor Plumbing & HeatingBSI Online2024-04-04T13:26:36+00:00

McGregor Plumbing & Heating

Tavistock | 519-655-2259
mcgkm@hotmail.ca

Mike Pope Plumbing & HeatingBSI Online2023-12-07T21:10:04+00:00

Mike Pope Plumbing & Heating

London | 519-673-5954
mpopeplumbing@gmail.com

Millcreek Plumbing & MechanicalBSI Online2023-12-07T21:10:45+00:00

Millcreek Plumbing & Mechanical

St. Thomas | 519-631-9180
reception@millcreekplumbing.ca

Mitch Lattimer PlumbingBSI Online2023-12-11T19:03:02+00:00

Mitch Lattimer Plumbing

Woodstock | 519-421-6032
info@MitchLattimerPlumbing.com

Oxford PlumbingBSI Online2023-12-11T18:59:26+00:00

Oxford Plumbing

Woodstock | 519-421-3017
Nmitchell@oxfordplumbing.ca

Pepper PlumbingBSI Online2024-05-07T10:49:24+00:00

Pepper Plumbing

Woodstock / 519-532-1538
jessica@pepperplumbing.ca

Peter Lawton & Son Plumbing Inc.BSI Online2023-12-07T21:11:38+00:00

Peter Lawton & Son Plumbing Inc.

London | 519-434-2306
peterlawtonplumbing@msn.com

ProActive Water Solutions IncBSI Online2024-03-05T14:27:33+00:00

ProActive Water Solutions Inc

Vaughan | 416-249-2837

Roberts Onsite IncBSI Online2024-01-03T13:57:51+00:00

Roberts Onsite Inc

Kitchener | 519-748-2758
wbarnard@robertsonsite.ca

Secure Water SystemsBSI Online2024-01-03T13:55:39+00:00

Secure Water Systems

Guelph | 519-827-9622
info@securewatersystems.ca

Thermal-Tech Mechanical LtdBSI Online2024-07-30T19:19:25+00:00

Thermal-Tech Mechanical Ltd

Breslau | 519-648-1200
louisam@thermaltechltd.com

Tilstra Plumbing Inc.BSI Online2024-01-04T16:44:41+00:00

Tilstra Plumbing Inc.

Embro | 519-421-9511
showroomsales@tilstraplumbing.com

Total Plumbing SolutionsBSI Online2023-12-07T21:16:28+00:00

Total Plumbing Solutions

St. Thomas | 519-933-0014
info@totalplumbingsolutions.ca

Transparent Backflow ServicesBSI Online2023-12-07T21:17:19+00:00

Transparent Backflow Services

Waterloo | 519-574-8776
darryl@transparentbackflow.ca

Triton Plumbing + ServiceBSI Online2023-12-07T21:18:11+00:00

Triton Plumbing + Service

London | 226-605-5390
aron@tritonservice.ca

Turner Plumbing & Heating LtdBSI Online2024-02-05T14:24:21+00:00

Turner Plumbing & Heating Ltd

Stratford | 519-271-2782
tsoper@turnerplumbing.ca

Verhoeve’s MechanicalBSI Online2024-03-19T13:41:47+00:00

Verhoeve’s Mechanical

LaSalette | 226-970-1985
colin.verhoeve@hotmail.com

W.C. Weinhardt Plumbing IncBSI Online2024-07-19T14:31:11+00:00

W.C. Weinhardt Plumbing Inc

Kitchener | 519-221-5709
wcweinhardt@gmail.com

WRC Purifying LtdBSI Online2024-02-05T14:25:19+00:00

WRC Purifying Ltd

Norwich | 519-863-3000
brian@wrcpurifying.com

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