2011
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
Please use a separate form for each device.
Fortheyear I). 0 II
D Initial test.. Complete entire form
c!f! Annual test.. Complete Part A only
Public Water Supply
r-/e
Account No.
~65
Block
Lot
Facility Name r7~t"lu...ta:rI .se~e; t)ktl1+-
./[_ J .
Address j/' e.et'lAiWd Ut' \,0t\ P pi ~~ (-' altS
Street City Zip
Type ~
CJ:lcv
Location of Device
13/t)u..)el ~""1
Device
Information
Manufacturer
W
Model
'! CYf a..r\
Check Valve No.2
Test
before
repair
Leaked
Closed tight
~
Leaked
Closed tight
o
G""
Opened at_psid
Date
m [ill] []ll]
Pressure drop across first check valve
~pSid
0,& t.&b+ ofJe.v,
M
o
Y
Describe
repairs and
materials
used
t) 1b~'lMb le. c!&AL4
} J..otoe \Lit Iv e. .
~epaired by_
Name H~~ i.= "Ul-t ~
Lic#
Date repaired:
Lill2J UliJ [ill]
M
o
Y
Final test
Closed tight [rl-'
Closed tight ~
Opened at s:~ psid
Date
[Qlli] [ill] WIJ
M 0 Y
Pressure drop across first
check valve.2!t- psid
Water Meter Number
Meter Reading
Type of Service: (check one)
~estic 0 Fire 0
Other
lMe,}.e(
Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device M meets, D does NOT meet, the requirements of an acc table containment device at the time of testing
I hereby certify t~egOing data to be correct. e::r ~ ~ -.iLl sD I -aD J'1.
Print Name G'Vt:<.. Certified Tester No. Expiration Date
agent) certification that test was performed:
t1~ tOl'1''c
Title
~}ts..... ?3/()
Telephone
Print Name
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 (
Representing
Address
City
State
Zip
~'P I'NGBRo-1 13(9/91)
TOWN CLERK
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information ,ncluding manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed By Desiqn Enqineer, Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health departmenUwater supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
, ,
, ,
}
! .
'J ~
T
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Public Water Supply Protection
Flanigan Square, 547 River Street, Room 400
Troy, New York 12160-2216
Report on Test and Maintenance
of Backflow Prevention Device
Please use a separate form for each device.
F or the year
o Initial test - Complete entire form
~ Annual test - Complete Part A only
~D (1
Account No.
Block
Lot
Location of Device
MeIer ?/f
Facility Name
Address W
Street
Device
Information
Serial Number
/ )9(,~
Line Pressure 95 psi
Test
before
repair
Leaked
Closed tight
~
Leaked
Closed tight
o
C2J'
Opened at ~ psid
Date
~ [lli] [2]ZJ
r:r:rvure d.rop across first check valve
"is. pSld
M
D
Y
Describe
repairs and
materials
used
Repaired by
Name
Lic#
Date repaired:
OJ OJ OJ
M
D
Y
Final test
Closed tight D
Closed tight D
Opened at _ psid
Date
Pressure drop across first
check valve psid
\ OJ OJ
M \ D Y
Meter Reading
Zyfo 0./
TYPe...;*$ervice: (check one)
rH1)omestic 0 Fire 0 Other
Remarks (Describe deficiencies: bypasses, outlets before the device, connections betwee the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device ~ meets, D does NOT meet, the requirements of an acce
I hereby certify the foregoing data to be correct.
9s-'1
able containment device at the time of testing
-1L/JDI aC>J'1
Expiration Date
Print Name
Certified Tester No.
(~~j"~ 73/0
Telephone
Certification that installation is in accordance with the approved pians.
(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 nstallattpj~CC ~ ~~~ [Q)
Address
City
State
Zip
/91)
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A- To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed By Desiqn Enqineer. Architect or Water Supplier for initial Tests Onlv
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health department/water supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
IT
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
Please use a separate form for each device.
For the year Q. (/ l \
o Initial test - Complete entire form
CfrJ Annual test - Complete Part A only
Public Water Supply
U'
Account No,
Block
Lot
Facility Name~ ~ R,'J.:y' Sewef" ?/4\"lt-
Address c.. 3 ~.\.,,"" f'I{" i;.J1l.t'Ji1lU.~,:J^ ;::;'Ab 1~f>-qO
Street City ,.., . Zip
TYRe L:id'Rpz
c::::J:l C V
location of Device
~I(g~''lOPtV\
Device
Information
Manufact~H5
Check Valve No.1
psi
Test
before
repair
leaked
Closed tight
g-
leaked
Closed tight
D
~
Opened at~ psid
Date
[Q]X] cmJ [ill]
Pressure drop across first check valve
~psid
M
D
Y
Describe
repairs and
materials
used
Repaired by
Name
Lic#
Date repaired:
CD CD CD
M
D
Y
Final test
Ciosed tight 0
Closed tight 0
Opened at _ psid
Date
CD CD CD
M D Y
Pressure drop across first
check valve _psid
Water Meter Number
Meter Reading
Typ of Service: (check one)
el"Domestic 0 Fire 0 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 [)fI meets, 0 does NOT meet, the requirements of an ac eptable containment device at the time of testing
I hereby certify the foregoing data to be correct
qs-l.f
--1L1.JQ.J ?O I '1
Expiration Date
Certified Tester No,
owner's agent) certification that test was performed:
Meda". l'
Title
(~>'~] - /sYe>
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
~OW~[fJj
AU6 2 6 2011
~ y 0 tW 'jjPIN~1013( /91)
OWN CLERK R
Date
NYS DOH Log #
License Number
Phone (
Representing
Address
City
State
Zip
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed By Desiqn Enqineer, Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health department/water supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12193
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
Please use a separate form for each device.
For the year
o Initial test - Complete entire form
~ Annual test - Complete Part A only
p'o U
Account No.
County Block
blJ~Le-s ~
Location of Device //!/~ lUeJ/ hoJd
(I, IOI'I~ e it:bp,.,
Lot
Facility Name t-ld He () i,~e..1 -f't.e.ld
Address 9 . P ed r l.Yt1. (:.000.....0 P ll..,\? e,r.s
Street City
F t...ll ') l~fJ-9<
Zip
Device
Information
Model
009 1'1
Check Valve No.2 Differential Pressure Relief
Valve
psi
Test
before
repair
Leaked
Closed tight
Ea-
Leaked
Closed tight
D
cg--
Opened at ~ psid
Date
Pressure drop across first check valve
-!iLl psid
[Q[]j [llij [ill]
M
D
Y
Describe
repairs and
materials
used
Repaired by
Name
Lie #
Date repaired:
rn rn rn
M
D
Y
Final test
Closed tight 0
Closed tight 0
Opened at_psid
Date
rn rn rn
M D Y
Pressure drop across first
check valve _ psid
Typ~ Service: (check one)
sDomestic 0 Fire 0 Other
Water Meter Number
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, D does NOT meet, the requirements of an ace
I hereby certify the foregoing data to be correct. 'i t> I..-f
a~b~
Certified Tester No.
~/~O/?OI~
Expiration Date
Print Name
Property owner's (Dr owner's agent) certification that test was performed:
j(t'-"'~ t}ofJI" fV7t'rI,4Q/r
Print Name Title
( <6'~ fJ/.3- }JIO
Telephone
Certification that installation is in accordance with the approved plans.
(To be completed by the design engineer or architect Dr water
supplier.)
I hereby certify that this installation is in accordance with the approved plans.
Name
Title
Date
NYS DOH Log #
License Number
Phone (
Representing
Address
City
State
Zip
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B _ To Be Completed By Desiqn Enqineer. Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health departmenUwater supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
'I" ,
( , '.1, _ ~;. '
i
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
Please use a separate form for each device.
Forthe year ~ 0 l (
o Initial test - Complete entire form
~ Annual test - Complete Part A only
Account No,
Block
Lot
Facility Name Hit l to~ L0c:Ll-Ctek)
q ~'":)~r RoV\
Address WU--ff' l~~l',(S [;:""a.Ll '::">
Street City
Location of Device
~
dllicy~) VeIl r;~/d
({'4/o(','t7f' ;0~~)
Device
Information
Manufacturer
t.U...
I?S-OLO
Zip
Model
e69 Q"'\
Check Valve No.2
Test
befo re
repair
Leaked
Closed tight
GV
Leaked
Closed tight
D
~
---
Opened at ~ psid
Date
fQ&J fM3 [iliJ
pfPt,ure d,rop across first check valve
,. pSld
M
D
y
Describe
repairs and
materials
used
Repaired by
Name
Lie #
Date repaired:
CD CD CD
M
D
y
Final test
Closed tight D
Closed tight D
Opened at _ psid
Date
CD CD CD
M D Y
Pressure drop across first
check valve _psid
Water Meter Number
".
Meter Reading
Ty" of Service: (check one)
Domestic 0 Fire ~ OtherC llJ. INLO ~~I~" J
Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc,)
Certification: This device IYJ meets, D does NOT meet, the requirements of an acce
I hereby certify the foregoing data to be correct. Cl S~
L." 1Uu.....f:>
Certified Tester No,
..iLl "3D I ;;? 0 I,
Expiration Date
r owner's agent) certification that test was performed:
~ f',AfIp,"-
Title
(GY.f)ff. 5- ;>YO
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 (
Representing
Describe minor in
Address
City
State
Zip
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed Bv Desiqn Enqineer, Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health departmenUwater supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
J .~
" \.'.~ ;
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
Please use a separate form for each device.
For the year
D Initial test - Complete entire form
'7J Annual test - Complete Part A only
~DII
Public Water Supply
aed
Facility Name Hdll-op wd { (,&
Address t:t Df#eJ{ f2. 1l... W /.(c"'y r Il..u,"/'5
Street ~ /tv./
Account No.
Location of Device
Block
lot
Device
Information
~h II,:> 1~4qO
Zip
Type GRpz
CJ:>CV
Model
Dcfiar-
Check Valve No.2
Test
before
repair
Leaked
Closed tight
~
leaked
Closed tight
o
!p
Opened at.!:L.2. psid
Date
mJ [Zlli] WIJ
Pressure drop across first check valve
-S2. psid
M
o
Y
Describe
repairs and
materia Is
used
Relr....o'\t"( C kt1{ Ie V.z)V f
(! /tt-II-\ lub(t<!ti~e
() ret{s"JelMble
r
C htC 1< V {;t 'Vt: sid I
~'t 'Cer( -
D Closed tight D
Pressure drop across first
check valve psid
Repilired by
Name .::!1....... E: 'If t-f /.00. ~
Lic#
Date repaired:
reEJ ~ rn
M
~..,.,;"
..~ ;w.~
.
o
y
Opened at _ psid '
Date
rn rn rn
M 0 Y
0'0/010
Typ~f Service: (check one)
&'Domestic 0 Fire 0 Other
Water Meter Number
Remarks (Describe deficiencies: bypasses, outlets before the device, connections betV(!'en the device and point of entry, missing or inadequate airgaps, etc.)
~e.,^",- - . ~ \..\ \ e-
Certification: This device D meets, fY1 does NOT meet, the reqUirements of an acc table containment device at the time of testing
I hereby certify the foregoing dat~e correct. ey c; i-f ~I 5D/~ 1.(
Print Name ;::r- a e-s t:7'v l i-\- Certified Tester No Expiration Date
Print Name
r 0 ner's agent) certification that test was performed:
/'1 t!c.LIJ."/c.
Title
(8'~j'_ 73/0
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 (
Representing
Address
City
State
Zip
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g.., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5;0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed By DesiQn EnQiheer. Architect or Water Supplier for Initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health department/water supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
NEWYORK 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
Please use a separate form for each device.
For the year
o Initial test - Complete entire form
9G Annual test - Complete Part A only
1,011
Account No.
15~k4 6)"
Block
Lot
Location of Device
Device
Information
2~70
Zip
ffiRPZ
L:J:lcv
Vtz(l/t! Pi 4
Line Pressure
psi
Test
before
repair
Leaked
Closed tight
~
Leaked
Closed tight
D
~
Opened at ~ psid
Date
6ID ~ UliJ
Pressure drop across first check valve
~psid
M
D
y
Describe
repairs and
materials
used
Repaired by
Name
Lie #
Date repaired:
rn rn rn
M
D
y
Final test
C.losed tight D
Closed tight D
Opened at _ psid
Date
rn rn rn
M D Y
Pressure drop across first
check valve _ psid
NO
~4t?t el
Meter Reading
of Service: (check one)
Domestic 0 Fire 0
Other
Water Meter Number
Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate alrgaps, etc.)
Certification: This device 0 meets, D does NOT meet, the requirements of an ac ptable containment device at the time of testing
I hereby certify the foregoing data to be correct. C) ',- U I I
\,~ I ~/30 170lLj
Print Name Certified Tester No. Expiration Date
owner's agent) certification that test was performed:
.}- n~~~r1!c.
Title
P{)~ /3'/0
Telephone
Certification that installation is in accordance with the approved plans,
(To be compieted 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
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A. To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sign your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B . To Be Completed By Desiqn Enqineer, Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health department/water supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93
,.~-
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
Please use a separate form for each device.
For the year
o Initial test - Complete entire form
~ Annual test - Complete Part A only
{Zo II
Public Water Supply
Account No.
Block
Lot
Location of Device
"b1<5u.!/er
Roo~?
Facility Name
Leaked
Closed tight
D
~
Size (in inches)
..J-
Differential Pressure Relief
Valve
Opened at ~ psid
psi
Device
Information
Manufacturer . I
t<..ktHS
Check Valve No.1
Zip
L9RPZ
CJ:>CV
Line Pressure
Test
before
repair
Leaked
Closed tight
~
Date
~ [Z[iJ rn
Pressure drop across first check valve
!l.iL... psi d
M
o
Y
Describe
repairs and
materials
used
Repaired by
Name
Lie #
Date repaired:
CD CD CD
M
o
Y
Final test
Closed tight D
Closed tight D
Opened at _ psid
Date
CD CD CD
M 0 Y
Pressure drop across first
check valve _psid
Meter Reading
TYP~ Service: (check one)
O(oomestic 0 Fire 0 Other
Water Meter Number
Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device IX] meets, D does NOT meet, the requirements of an ac
I hereby certify the foregoing data to be correct. q f.) t..t
ptable containment device at the time of testing
I
..JL/:JQ.J~
Expiration Date
Print Name
Certified Tester No.
clal~-731'()
Telephone
ner's agent) certification that test was performed:
r'1~t;.4,,~/f...
Tille
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
.,,, 'rF!r~ ((; ~UW'~{Q)
AU~ 2'
In ays 0 t e testing e .
WN DOH-1013(91 1)
0;::
TOWNVvAPPINGER.
CLERK
Date
NYS DOH Log #
License Number
Phone (
Representing
Address
City
State
Zip
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE
PART A - To Be Completed by Certified Tester
. Indicate the test year and whether initial or annual test.
. Complete public water supply name, customer account number (if available) and county.
. Complete block and lot (if available) for New York City Metropolitan area tests.
. Complete facility name, address and specific location of device (e.g., meter room, etc.)
. Complete device information including manufacturer, type, model, size and serial number.
. Complete section "Test Before Repair" and indicate:
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
and/or repaired.
Complete water system line pressure in psi and indicate test date.
. Describe any repairs and materials used and the name and license number of the repairer and indicate repair
date.
. Complete "final test" section only if repairs have been made.
. Indicate the water meter number/meter reading and the type of service (describe "other" e.g., boiler feed,
irrigation line, etc.)
. Complete the Remarks section if there are any deficiencies.
. Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
print and sigh your name and indicate certificate number and expiration date.
. Have the property owner (or owner's agent) certify that test was performed.
PART B - To Be Completed By Desion Enoineer, Architect or Water Supplier for initial Tests Only
. Complete name, title, license number, phone number, company name and address.
. Sign and date form and indicate NYSDOH (or local health department/water supplier).
. Describe minor installation changes.
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester's personal records.
Revised 12/93