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2014
' NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Empire State Plaza -Corning Tower Room 1110 Albany, NY 12237 " ep , ~ on Test and Maintenance of ~aclkflow Prevention ®evice _ Please use a separate form for each device. For the year ~() i ' ~ Initial test -Complete entire form Annual test -Complete Part A only Public Water Supply Acccunt No. County Block Lot ~ ~~ , v~. rru --ChPSs Facility Name // (~~~ n t C.~~~ Sr' ~r' r Location of Device 1~~w ~(/C c~ ~~l ' (~ r r i., ~ k1 Address~Cw f-16it'KrL~~nC I~ )!'it~ Wutn:nlL r i ~ I~rl~. Street. City ~ Zip i 25 %U Device Information Manufacturer Type 0 RPZ Model Size (in inches) t Serial Number Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure ~,_psi Valve Test before Leaked ~ Leaked ~ Opened at~ psid Date Closed tight Closed tight ©.- _ ~ - ~ repair , ~ U ~ Pr sure drop across first check valve psid M D Y Describe repairs and materials used Name Lic # Repaired by Date repaired: m m M D Y Final test Closed tight e Closed tight ^ Opened at psid Pressure drop across first check valve psid Wt Date ~ m M D Y a er Meter Number Meter Reading Type of Service: (check one) i ~~ ` ~~ ~ Domestic ^ Fire ^ Other Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) Certification: This device ~ meets, U does NOT meet, the requirements of an I hereby certify he foregoing data to be correct. Print Name ~~~ , a~ A La. ~~. !-~ t ; :. Certified Tester No. containment device at the time of testing 7 ~l ~ ~l~ Expiration Date Property owner'/s (orow er's agent) certification that test was performed: ~~! ~7 ~~~~~ r Pnnt Name Title ~~ Si nature Telephone CertlfCatlon that Installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title License Number Phone ( ) Representing Address City State Zip Signature Date m d Describe minor installation changes Y NYS DOH Log # ompietea copy to the tlesignated health department representative and one copy to the water supplier within 30 days of the testing device. owner and water supplier immediately if device fails test and repairs cannot immediately be made. DOH- 1013(9!91) ivwv Lunn a iHi t utrr,rc im~iv i yr n~r~~ i n Bureau of Public Water Supply Protection Empire State Plaza -Corning Tower Room 1110 Albany, NY 12237 Report on Test and Maintenance o~ ~ac~flo:~~ pre:~ention ©evice riease use a separate form for each device. ' "' "'° "°' '~ " ' 0 I iti l t n a est -Complete entire form A l t t C nnua es - omplete Part A only Public ater Supply ~ Account No. County Block Lot Ll I Cr!~ Lv~( t Z'`' VvE'l ' ~ X~V ~r!v~~,J~ r //~~ Facility Name ~"J '~`~ j,'Jl~~ ~~~CI Location of Device ~G/~ ~~O ~ Address ~ ~ ~ h~L ~ ~Y'1.. ~~ ~ rU,yp~~ (~~~ f h1~5 ~~i~0 Street. City Zip Device Information Manufacturer jjlf,L~~~ ~~11 ////~~~~~~11 Type ~ RPZ ~ DCV Model ~C ~l~'1/ (~ ~"" Size (in inches) ~ / Serial Number y~ ~/~ / j ~ / Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure psi Valve ~U S Test Leaked Leaked 0 O ened at ~~ ~ p epsid Date before Closed tight Closed tight ~. ~ ~ ~~ ~~ repair L-L!J Pressure drop across first check valve ~': ~i sid M D Y p Describe repairs and Repaired by materials Name used Lic # Date repaired: m M D Y Final test Closed ti ht 9 Closed tight ^ Opened at psid D ate m Pressure drop across first M D Y check valve psid Water Meter Num b er ~ Meter Reading Type of Service: (check one) ~ p y (i' ~^1 r ~~ omestic ^ Fire ^ Other Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) Certification: Thi d i ~ ~ s ev ce meets, does NOT meet, the requirements of an a eptable containment device at the time of testing I hereby certify the foregoing data to be correct. C~ ~ ~ a ~ ~ /Y~` ~ ~ ( t `~ f / Print Name` Certified Tester No. i' Si ure Expiration Date '~ I/taC'` ~! / ~ Prop e//rty o wn/er's er's agent) certification that test was p erformed: So ow, JJ l / ` / i P N // ~ -' r n ame Title Signature Telephone CerflfCatl0n that Ir1StallatlOn IS In aCCOrdanCe Wlth the apprOVed plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title Date NYS DOH Lag # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature - • -• --••- -~~- --~~~r~~•=~ ~~rr ~~ ~~~~ ~=~~a~ ~_«~ ~iccun ~Gpd~ anent represeneauve ane one copy to the water supplier within 30 days of the lesUng dewce. Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made. DOH- 1013(9/91) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180.2216 Report on Test and Maintenance of Backflow Prevention Device Nlease use a separate form for each device. "' "'°'°°' 0 Initial test- Complete entire form ~ Annual test -Complete Part A only Public Water Suppl ` Account No. County Block Lot tll~tS Facility Name ~y/~ ~(i~/ ~G~~ Location of Device n / /~n~G ~~ (~/ Address Street City Zip Device Manufacturer Type RPZ Model Size (in i ches) Serial Num ber Information ~CV u ~ /~ Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure 9'~psi Valve Test before Leaked ~ Closed tight Leaked ~ Closed tight ©~' Opened ai ~ psid- Date ~ Z ~ ~ ~ repair Pressu a drop across first check valve M D Y psid Describe Repaired by repairs and ~ Name materials used Lic # Date repaired: m m M D Y Final test Closed tight ~ Closed tighi ~ Opened at psid Date ~ m Pressure drop across first M D Y check valve psid Water Meter Number Meter Reading ~A,I 11 Type rvice: (check one) D ^ /~., .6 9~~5 ~(I Domestic ^ Fire ^ Other Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, efc.) Certification: This device meets, ~ does NOT meet, the requirements of an ace table containment device at the time of testing I hereby certify a foregoing data to be correct. / 1 f~f j 1{ Print Name ~~ ~ ~ Cerlitted Tesiar No. SI a ure Expiration Date _~- Property owner's (or net's agent) certification that test was performed: v ~ ~/c r~~cl~n.~ (~~3 7,~~ /l~i~~i / Print Name Titlo S nature Telephone Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title Date NYS DOH Log # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature NO7"L==: Send one completed copy to the designated health department representauvo ana one copy come wace~ s~py~~r~ ~~~~~~~~ ~° ~oy~ °~ .,~° ._,.~,~y ....•,~~. DOH-1013 9191 Notify owner and water supplier immediately if device falls test and repairs cannot immediately be made. ( ) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180-2216 V~~`®®~~ ®~u ~°~~t~ ~r~~ ~d~aw~~r~~r,~~~ ®~ ~ac~Cftl®w V~rr~v~r~~u®a~ ®~e~u~~ nr>>N Please use a separafe form for each device. "' "'°'°°' -~`-" ' 0 initial test - Complete entire form Annual test -Complete PartA only Public Water Supply ( Account No. County Block Lot ~ ~n ~ f ID ~ kk~ 1, r Facility Name ~ sc~r~r5._ ~t9 N+~ S'(-~~-~~Grl -4/~ Location of Device V Y~L~1~ Y ~ ~j ` Address~.lr/ fO[z'tf1~ P[LtL"1' 4~(~~,vri,~/3 1~/~ll~ 1~,'~ ~O Street City r Zlp Device Information Manufact r,e,r1 i~ ~ Type RPZ Model ~ Size (in inches) ~ Ser'al Number ~'f'S• ~CV Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure ~,~psi Valve Test Leaked ~ Leaked ~ ~ ^~ Opened atJ • $ psid Date before Closed tight Closed tight 0 repair P essure drop across first check valve M D Y psid Describe Repaired by repairsand• ~ Name materials Lic # used Date repaired: m m M D Y Final test Closed tight ~ Closed tight ^ Opened at psid Date m m Pressure drop across first ~ M D Y checkvaive psid ~ ~~ Water Meter Number Meter Read(ng Type of Service: (check one) ~ Domestic ^ Fire ^ Other Remarks (Describe deficiencies: by asses, outlets before tho device, connections betweon the device and point of entry, missing or inadequate airgaps, etc.) ~ does NOT meet, the requirements of an acc ptable containment device at the time of testing This device ~ meets tl C rtiFl , ca on: e I hereby certify the foregoing data to be correct. 9 ,) / ~(~ / ~ ~ ~ . Si ure Expiratloration Date - Print Name ~ Certifiod Tester No. Property owner's (or own is agent) certification that test was performed: (~~ ~- ~ ~ r1 ~ f~ a .iC ~~~~f ~~ - , , ~ . i r Print Name TItIo Slg t e Telephone Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify thatthis installation is in accordance with the approved plans. Name Title Date NY5 DOH Log # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State ZiP Signature Ol'L-: Sen Notify ownler and wate~ supplier Immed(ately If devieo fsilsrtest andt epairsn annot Immediately be madB 1er W'""" ,U °~y' V1 ~ ~~ a Vy. Vy DOH-1013(9!91) Bureau of Public Watef Supply Protection Flanigan Square, 547 River Street, Roam 41717 ~~6m®r~~ ®r~ ~'~~~ ~r~~9 ~~0~~~~~~~~ Troy, New York 12180-2216 ®~ tl~h~t~~>~~®~ li ~~~~~110®~ ©~~~l~o~ . Ill ,~, f711.1 _ Please use a separate form for each device. ` "' "'° y°°' - ~' (~ Initial test- Complete entire form Annual test-CompletePartAonly Public Water Supply Account No. C\ounty Block Lot i ~' in / ~ E ~ -JV ~C~S 1 S~~ ~ ~~ ' Location of Device (~c " '/I ~ C a 10. dyLfb['~ Utr+D Facility Name 1 ` r/ ~ / t°i 1 ~~ 1 ~5 Q~ / •~ ~ ~ t Address Ur OiDrl1t.~vt5 ~ ~~5~ t~l~- L - Zip Street Cit ~ Device Manufacturer Type 0 PZ Model Size (in inches) Serial Number Information ~CV (')p J ~~ ~~ Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure si Valve Test Leaked ~ Leaked 0 - Openedat~psid Date ,/ ~ 7 7 ! before Closed tight Closed tight ~ i Y repair Pressure drop across first check valve M D Y ~(~ psid Describe Repaired by repairsand• %• Name materials ' d Lic # use Date repaired: m m M D Y Finai test Closed tight ~ Closed tight ^ Opened at psid Date m m Pressure drop across first M D Y check valve psid Water Meter Number ~ Meter Reading ~` ~ Type Service: (check one) ^ ^ yg ' 7yJ 0 3 7 / ~ Other Fire Domestic Remarks (Descr)be deficiencies: bypasses, outlets before the device, connections betwoen the device and point of entry, missing or inadequate airgaps, etc.) ble containment device at the time of testing t f i ~ ~ an act a s o remen does NOT meet, the requ meets, Certiftcation: This device 1 hereby certify the foregoing data to be correct. ~~ 1/ I'JV! l Print Name l~~s Cerlifiod Tester No, Sig lure F~cpiratlon Date Property ow~7er's or oa~rr is agent) certification that test was performed: Print Name Tltlo Sign re Telephone Certification that installation is (n accordance with the approved plans. (To ba completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title Date NYS DOH Log # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature N01' -: en one completed copy to the designated health department representauva ana one copy [o me water suppler wuuw ~~ ~°y~ ~~ 4~° ~~~.~~ ~a ~~•~~~• DOH-1013 8191 Notify owner and water supplier Immediately if device falls test and repairs cannot immediately be made. ( ) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180-2216 Report on Test and Maintenance of Backtlow Prevention Device ~~ ~ N Please use a separate form for each device. "' "'°'°°' 0 Initial test- Complete entire form Annual test -Complete Part A only Public Water Supply Account No. County Block Lot ' 1 ~,I1 ~ w t` ("~i 1~ ` Location of Device n ~1 ~ (~ ~ i ~ ~ Facility Name I ` ~ ~ V 1~ „opr~, Address ~t~2!tr ~ ~l Wlt~/~~ ~,a~l hyXS i 7~5`~t'U Street Ci Zi p Device Manufacturer /~ r~-~ Type ~-'•RPZ Model Size (in ' ches) , Serial Number Information ~~ ~CV ~ , 3773 Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure~~psi Valve Test before Leaked t~ Closed t(ght t~ Closed tight ~/~ Opened at ~ psid Date ®~ T I l I `f I repair Pressure drop across first check valve M D Y G.Y psid Describe Repaired by repairs and Name materials used Lic # Date repaired: m M D Y Final test Closed tight ~ Closed tight ^ Opened at psid Date ~ m m Pressure drop across first M D Y check valve psid Water Meter Number eter Reading ~~ M Type o rvice: (check one) C~ _` O dc3J 7 Z`l~6 omestic ~ Fire ~ Other Remarks (Describe deficiencies: bypasses, outlets before the dovice, connections between the device and point of entry, missing or inadequate airgaps, etc.) ~ does NOT meet, the requirements of an acc table containment device at the time of testing Certificat(on: This device ~ meets, I hereby certify the foregoing data to be correct. ,~~ ' 1 `~~ u Print Name ~Q ~~ k k5 Certified Tester No. SI re Expiration Date Property owner's (or ow}e sag nt) certification that test was performed: ~'l~rj~G (~~~ ~ ! ~'~~ ~C .. ~l Print Na a Titlo S' nature Telephone CertlfiCatlOn that 111Stallatl0n IS In aCCOrdanCe With the appfOVed plans. (To be completed 6y the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title Date NYS DOH Log # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature NOTE: Send one completed copy to the designated health department representative and ono copy ro the wafer suppuerwmm~ ou aays u~ sue ~n~~n~y ~~~~~o. DOH-1013 9/91 Notify owner and water supplier tmmediately if device fails test and repairs cannot immediately be made. ( ) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Slreel, Room 400 Troy, New York 12180.2216 ~~~®~~ ®r~ ~~~~ ~r~m9 ~~a~~~;~m~~~~~ ®~ ~a~~~9®w V~rr~v~r~t~u®r~ ®~eeu~~ ~c~l~ t'lease use a separate form for each device. °' "'°'`°' 0 Initial test- Complete entire form Annual test -Complete Part A only Public Water Supply ~ ~ V V r l Account No. County (~ }~~ ~S Block Lot . ,r y~ ~ Location of Device 1 p Facility Name 1~8V0.\ ~~ Q . l]C.~t l~ ~ - - ~.Ogtf'0` tl.B~ ~ . AddressG3 1Ma~/~-1-+ ~7~~ tJ~t,~n~~C''~ ~v~1s i~S~~ Street Cit " Zip Device Manufact er Type RPZ Modei Size (in i ches) Serial Number Information ,~,~5 OJCV ~ Q~ 3 / 7731 Check Valve No.1 Check Valve No. 2 Differential Pressu Relief Line Pressure~~psi Valve Test Leaked ~ Leaked 0 d Opened at Z+~e psid Date ~ Z before Closed tight Closed tight i repair P essy~ drop across first check valve ~b psid M D Y Describe Repaired by repairs and • ~ • Name materials Lic # used Date repaired: m m M D Y Final test Closed tight ~ Closed tight ^ Opened at psid Date ~ m Pressure drop across first M D Y check valve psid / ~ Water Meter Number 1 / Meter Reading Type o~f ervice: (check one) ' ^ ~ ~ ~ fw ~`~_ ~7l LY Other Domestic ^ Fire Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, m(ssing or inadequate alrgaps, etc.) tainment device at the time of testing o t bl f ~ ® a e c n an ac does NOT meet, the requirements o meets, Certification: This device 1 hereby certify the foregoing data to be correct. R ~~ , I ~ 1 ~ ,rl ` tJ l Print Name Certified Tesier No, 51 ature Expiration Date 1~-5 " \l ~a Property owner's (or owner's agent) certification that test was pertormed: Print Name Tillo Sig ture Telephone Certlf CatlOn that installation 15 In aCCOrdance Wlth the appfOVed plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Titie Date NYS DOH Log # L(cense Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature NOl L=: Send one completed copy to the designated health department representabvo and one copy to me water suppler wmnn ov unys u~ ~~~~ .o„~~.y „~.~..o. DOH-1013 9191 Notify owner and water supplier immediately if device Tails test and repairs cannot immediately be made. ( ) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180-2216 Report on Pest and iilllaintenance ®f ~ack$!ow Preventi®n ®evice L~l crease use a separate Corm for each device. "' "'° r°°' ' ' 0 Initi l t t C a es - omplete entire form Annual test -Complete Part A only Public Wa`er S t ply l Account No. County Block Lot ' r/ IS ~u~S --~^ t ~ Facility Name _ /own e~ ~o,~ n ~ T Location of Device /i~f (~. t~ y, ~-p Address ! lr.~S ~ ~n16~~ ~ ~ ~ i.J ' Oa/J (~i ~rri f~U~~9 //~D 7 --- St~ ~ it Z(p Device Information Manuf cturer ~ Type RPZ Model Size (in inches) Serial Number ism ~CV ~, Z ~5 ~ t~~--' Check alve No. 7 Check Valve No. 2 Differential Pressure Relief Line Pressure, ,?n _psi Valve Test before Leaked Closed tight ~ Leaked ~ Closed tight r7~ Opened at 2,•~psid Date ~ Z repair P re s sure drop across first check valve M D Y ' - u psid Describe Repaired by repairs and ~ Name materials used Lic # Date repaired: m m M D Y Final test Closed tight Closed tight ^ Opened at psid Date m m Pressure drop across first M D Y check valve psid Water Meter Number ~ dG~~ Meter Reading ~ ~ y Z 3 ~- T~~ype~~of Service: (check one) L~D ti ^ Fi ^ O h 7 b V D omes c re t er Remarks (Describe deficiencies: bypasses, outlets before the device, connections betwsen tho device and point of entry, missing yr inadequate airgaps, etc.) ~ does NOT meet, the requirements of a Certification: This device ~ meets, n acc table containment device at the time of testing I hereby certify the foregoing data to be correct. ,, 1t f ~ ~ f ~ ~ t ,,, r ~ Print Name ~ -~ Cerlifled Tester No, . t na ure F~cplratlon Date rtormed: Property o ner's (or o ~her's agent) certification that test was pe / i ~ 9f/G ~CGNA6HiL (~~ if r b,~ J.3fO Print ame T(tlo Sig ature Telephone Certification that installation Is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify that this installation is in accordance with the approved plans. Name Title Date NYS DOH Log # License Number Phone ( ) m d y Representing Descri be minor installation changes Address City State Zip Signature NOTL=: Send one completed copy to the dellg~ated health department represen[attvo one one copy [o [ne water suppuer wt[nin su eays o[ [ne [esung eewce. Notify owner and water supplier Immediately If device fails test and repairs cannot immediately be madde. DOH-1013(9!91)