Cross Connection - Form Requirements

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The following information is required on all test report forms submitted to the City. Items 1 through 12 are standard information required on all forms.
  1. BAT Certification Number.
  2. Name: Name of business or property owner.
  3. Address: Your building or residence street address.
  4. Device Location: Please give the physical location of the device, such as next to meter, west wall of room 102, 15 feet SW of building, etc.
  5. What the Cross-Connection Hazard Is: Backflow devices isolate such things as irrigation systems, carbonation machines, boilers, etc.
  6. Size/Type: Size and type of backflow preventer, such as ½-inch DCVA.
  7. Manufacturer.
  8. Name, Serial Number: Be accurate. Include alpha prefixes, such as A120220.
  9. Model Number/Model: Use complete model number, such as 009M2QT or 950XLT.
  10. Proper Installation Annotation: Forms must note if the assemblies were installed in accordance with the installation requirements. If the assembly does not meet these requirements, the discrepancy must be recorded in the comments section.
  11. Comments Section: Record any comments or discrepancies in this section. For example, if an assembly does not meet the proper installation requirements, note the reason in this section.
  12. Test results: To include the following:
  13. Values required for each check valve tested.
  14. Repair information and details.
  15. Final test results.
  16. Test Equipment Information: Record the gauge, make, model, serial number, and verification date.
  17. Certified Tester Information:
  18. All test reports must include legibly printed tester's name, telephone number, certification number, test completion date, gauge serial number, and gauge verification accuracy.
  19. Person Repairing Assembly: Printed or typed name of person repairing assembly.

Questions about cross connections? Contact Steve Coke, City of Olympia, Public Works Department, at 360.753.8161, or send an scoke@ci.olympia.wa.us.

Need a permit? Contact the City of Olympia Community Planning and Development Department, at 360.753.8314, or send an cpdinfo@ci.olympia.wa.us.

Need related water quality information? Contact the Public Works office.

  • Physical Address: 924 7th Ave. SE, Suite A
  • Mailing Address: PO Box 1967, Olympia, WA 98507
  • Download printer-friendly (PDF) directions to our office
  • Hours: Monday - Friday from 8:00 a.m. to 5:00 p.m.
  • Phone: 360.753.8588
  • Email: publicworks@ci.olympia.wa.us