Appendix H: Backflow Incident Report Form – Canadian Water Protection

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AWWA Canadian Cross-Connection Course

Course Overview
Acknowledgements
Disclaimer
Guide to Figures & Tables
Preface
Terms & Definitions
Acronyms / Abbreviations

Chapter I: Introduction to Cross-Connection Control
Introduction
What are Cross-Connections?
What is Backflow?
Hydraulic Principles of Backflow
Hydraulic Principles of Back Siphonage
Hydraulic Principles of Back Pressure
Summary

Chapter 2: History, Health & Legal Aspects
Introduction
Examples of Backflow Incidents
Health Hazards of Cross-Connections
The Multi-Barrier Approach
Legal Liabilty Associated with Cross-Connection Control(2)
Jurisdictional Responsibilities
Plumbing Code Compliance in Canada
Summary

Chapter 3: Determining Risk Factors & Selecting Appropriate Backflow Protection
Introduction
Determining Risk Factors
Backflow Prevention Methods and Devices
Selecting the Correct Type of Backflow Preventer
Summary

Chapter 4: Backflow Preventers
Introduction
Air Gap
Reduced Pressure Principle & Reduced Pressure Principle Detector
Double Check Valve Assembly & Double Check Detector Assembly
Pressure Vacuum Breaker & Spill Resistant Pressure Vacuum Breaker
Atmospheric Vacuum Breaker
Air Space Type Vacuum Breaker
Hose Connection Vacuum Breaker & Hose Connection Dual Check Vacuum Breaker
Laboratory Faucet Vacuum Breaker
Dual Check with Atmospheric Port
Dual Check Valve with Atmospheric Port for Carbonators
Dual Check Valve with Intermediate Vent
Dual Check Valve
Single Check Valve Assembly for Fire Systems
Barometric Loop
Water-using Equipment with Built-in Backflow Protection

Chapter 5: General Backflow Preventer Installation Requirements
Introduction
General Installation Requirements
General Installation Guidelines
Services That Require Year-Round Operation
Services That Are Shut Off During Winter
Summary

Chapter 6: Application of Backflow Prevention Procedures
The Location of Backflow Protection
Introduction
Fixture Hazard Classification Guide
Premises Isolation Hazard Classification Guide
Typical Facilities Where Premises Isolation is Required
Typical Facilities Where Premises Isolation is Recommended
Typical Systems Where Internal Protection is Required
Municipal Application (Typical Distribution System Hazards)
Guide to Conducting a Cross-Connection Control Premises Survey
Summary

Chapter 7: Maintenance, Testing & Troubleshooting
Introduction
Tester Training and Certification
Testing Equipment
Maintenance, Repair and Testing Guidelines
Testing Procedures of Testable Backflow Preventers

Chapter 8. Developing a Cross-Connection Control Program
Purpose of a Cross-Connection Control Program
Types of Programs
Program Administration
Elements of a Cross-Connection Control Program
Safety
Summary

Appendix A: References & Resources
Appendix B: Administrative Procedures of National Certification Program in Canada
Appendix C: Backflow Prevention Test Report Form Examples
Appendix D: Backflow Prevention Test Tag Example
Appendix E: Condensed Test Procedures
Appendix F: Accuracy Verification for Test Equipment
Appendix G: Cross-Connection Survey Report Form Example
Appendix H: Backflow Incident Report Form
Appendix I: Overview of the Elements of a Cross-Connection Control Program for Small Systems
Appendix J: Symbols

Test #1 RP- Relief Valve
Test #2 RP-Reverse on CV#2
Test #3 RP-Diff on CV#1
Test #4 RP-Static Line
Test #5 RP-Diff on CV#2 (Method 1)
Test #5 RP-Diff on CV#2 (Method 2)

Test #1 -Air inlet valve
Test #2 -Push a pound on CV#1
Test #3 -Static Pressure
Test #4 -Diff on CV#1
Complete Tests

Test #1 -Diff and Push a Pound on CV#1
Test #2 -Diff and Push a Pound on CV#2
Test #3 -Static Line
Complete Tests

Appendix H: Backflow Incident Report Form

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