2012NEW 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
2 r•7c n
Please use a separate form for each device. """' "- ' ~'
0 Initial test - Complete entire form
Annual test-CompletePartAonly
Public Wafer Supply Account No. County
(( Block Lot
__
) /~ / ~ L ~.
J~ /~-. ~~; ^1 t7 ~~ f 10%~1
Facility Name ~11tG1 M f; Location of Device ~ ~ j _
l~~t~~C'/° f ~ r
1
Address Ito ~ce~A ~' F Lf)LC ~~/,~j~~ 1 ~~qD
Street City Zip
Device Manufacturer Type RPZ Model Size (in inches) Serial Number
Information ~ ~ ~~r ACV ~j(-}' •~ ~- L
Check Valve No.1 Check Valve No. 2 Differential Pressure Reltef Line Pressure r °~ psi
Valve
Test Leaked
~ Leaked 0
'... Opened at ~ ~ L'' psid Date
~ Z
before Closed tight Closed tight Q
repair
Pr. s drop across first check valve
` +psid
--
M D Y
Describe Repaired by
repairs and
materials
~EC o 2012
3 Name
Lic #
used
T WN p~ WAPPI GER I Date repaired:
TOW IV-- CLE _ K_.._._ IZl 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 Meter Reading Type of Service: (check one)
7 ~~O Domestic ^ Fire ^ Other
Remarks (Describe deficiencies: bypasses, outlets before the device, connections belwoen the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device ~ meets, ~ does NOT meet, the requirements of an acc ptable containment device at the time of testing
I hereby certify the foregoing data to be correct. ~ ~ ,~ ~f~Q I f !~/
Print Name ~ ~~ ~ V U ~ Certified Tester No. Sl ature Expiration Date
Propert n, r's.(or er~s gent) certification that testwas performed: l,.
Print Name Tillo Sig`na re Telephone
CertlfCatlOn that insfallatlon IS 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 #
License Number Phone ( ) m d y
Representing Describe minor installation changes
Address
City State Zip
Signature
NOl'L•: end one completed copy to the desf~nated healt department representalivo and one copy to ma wafer suppuer wnn~~ ~ ~u uay~ ~, ~~ ~o ,o~.,~ ~y ..~.~~~• DOH-1013 9/91
Notify owner and water su{ipller immediately if device falls test and repairs canna( immediately be made. t )
INSTRUCTIONS FOR COMPLETING DOH-1013 9191)
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 Design Engineer 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