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2013
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. `"' """ ""' "- `" " -~ ~ Initial test - Complete entire form ~~ ~yt' Annual test -Complete Part A only ~~ Public Water Supply Account No. County Block Lot ~ ' ~ , W I lam/ l ~ S O Location of Device i ~ ` ~ ~ 'r ' Facility Name.. A)Ct,~« eey IPr l0 LJ ~ ~ r Y rk Z I ~ GtN Address ~.D ~cct1~T ~~ t°~ ~ rrS .~/a ~~~ i ehh !(~ 1Mln vt ~n v~ ~ Street City Zip ' Device Manufactur r Type ~RPZ Model Size (in inches) Serial Number information K ~ ACV ~ D ~ ' Check valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure psi Valve Test Leaked q / Leaked 0 ~ Opened at 3.8 psid Date ~ ~ m before Closed tight Imo' Closed tight ~ repair sure drop across first check valve _._ _.- -.-..--------------~~-~ M D Y psid ~ D •Z Describe Repaired by repairs and t i ls c DEC O 6 212 N me ma er a used Li # T W ~= VUI~PPINGE i d D t V a~1IN_ CLERK orepa re : ~ 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) ~' ~ FY ~~L~ ~,~,f, [ .r--- 1 Other Domestic ~ Fire Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) e able containment device at the time of testing f i t ~ © an acc s o remen does NOT meet, the requ meets, Certification: This device I hereby certify the foregoing data to be correct. µ~, ~ ~ ~ 1 13 ~l ~ Z,/ / " / _ 6 ig ture Expiration Date . Print Name ~ ~S L ~~k~ Certified Tester No Property owner's (r wner's agent) certification that test was performed: olY,~~~ ~l~ M~~a~,G (~.~~~ Print Name Title Si nature Telephone Certification that installation is in accordance with the approved plans. (To ha 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 NOTL•: Send one completed copy to the designated health department representauvo ana one copy cv me we~e~ suppur~ wu~~~~ ~ ~~ ~oy~ .., ~„~ .o~.,~,a ~~•~~~. DOH-1013 9f91 Notify owner and water supplier immediately if device falls test and repairs cannot immediately be made. ( ) 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. • V1lhether 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 grid address. ^ Sign and date form and indicate NYSDOH (or local health department/watersupptier). ^ Describe minor installation changes. After completion, submit copies of test reports to the supplier of water, customer, State or local heatth 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 Yest and iViaintenance of Backflow Prevention Device a'1~~i-~ Please use a separate form for each device. "' "'~'`°' I~ I iti l l n a test- Comp ete entire form Annual test -Complete Part A oniy Public Water Supply ~~ee~~-c~ctir~G~ ~ ~-ee' Account No. County t7c~Fr,1-~.~ Block Lot fJ) / ~ ~ ~ ~ S ~~ Location of Device ^~ ` (~ - el-c~~ ~ <B~C Lc>b© [1~1 Facility Name ~Ei~,:•+~, 64~+.e~zC ,,~~ Address /~~f~°~'uJOo~J ~!'ftf.L° LI/L/~ckhP.f'7 ~!•!lS Street City -~ Ztp ~ () Device Manufacturer Type RPZ Model Size (in inch s) Serial Number Information (~~1- ~CV [~~~ (~+ SYI~C`~ Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure psi Valve 7 Test Leaked ~ Leaked 0 ' Opened at `t'• ~ psid Date CU ~ ~ ~ before Closed tight Closed tight Q a q repair Pres re drop across first check valve M D Y psid Describe Repaired by repairs and ~ Name materials used ' ~f~. G~~ IL: ~/'1 I,l ,'r ~~ ~~~D ~ _ Date repaired: mm~ AN142013 M D Y Final test Closed tight ~ ~ '~(21~os ~~ GE pened at psid Date m m t R ~y Pressure drop across first - - pp ~~~~i ~'~1 -.., ,_,,,~, check valve psid - Water Meter Number Meter Reading Type of Service: (check one) ~, b 1~•r. ~V Domestic ^ Fire ^ Other Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) ti i f ~ e tes ng me o does NOT meet, the requirements of an acceptable containment device at the t meets, Certification: This devic I hereby certify the foregoing data to be correct. ~ 5 Print Name )•Ui Certified Taster No, gnature Expiration Date Property owner's (or ow is agent) certification that test was performed: Prin[ Name Tillo Si ature Telephone CertlfiCatl0n that installation IS In aCCOfdance 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 Log # License Number Phone ( ) m d y Representing Describe minor installation changes Address City State Zip Signature N 1'E; Send one completed copy to the esignated health department representative and one copy ro ma wager su pner wnnm ou uays of use ~o~uny ~~~~~o. Notify owner and water supplier immediately if device fails test and repairs cannot immediately be ma e. DOH-1013(9191) NEWYORKSTATEDEPARTMENTOFHEALTH Report on Vest and iVliaintenance Bureau of Puhlic Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, NewYork1Z16o-2216 of Backflow Prevention Device For the year ~,r~ V 1 Please use a separate form for each device. ~ Initial test - Complete entire form Annual test -Complete Part A only Public Water Supply _ ~ ~ rti t ~-e~i ~ c;-~•~~ Account No. I County I Block I Lot n t ` Location of Device ~ry l Facility Name'1UiY1,~_Ci~4Jc°uo,~YyC°i.~"ta~NL'Y. l ~~`~~-b~ ~bC~~ r-a -~ ` Address ~ ~ YN Gt~`~1 k Ji7 Y'- j,,.,TG<~ao) ~4 p'S l G~`~ ~ ~ ~ ~~ ~ a- :b v ~ ti''~ _ Street City ZAP ~;(b Device Manufact rer Type ~RPZ Model Size (in inches) Serial Number Information ~~ - ~CV C> p ~ .3 ~ y Check Valve No.1 CheckVaive No.2 Differential Pressure R ief Line Pressure psi Valve Test Leaked ~ Leaked ~ Opened at~psid Date © i ~ A ' ~ before Closed tight Closed tight [~' 1 L repair Pressure drop across first check valve M D Y ~}'• ~C psid Describe repairs and materials used JAN ~1 U 2013 TG'~~~'~ Y ;". I,~t,-'d~PINGER Final test Closed tight U Pressure drop across first check valve psid Repaired by =~! h ` ~J !_L, ~ 1°/ ~ D I Name Lic # Closed tight ^ I Opened at psid Date Water Meter Number Meter Reading Type of SeNice: (check ohe) 1 __ ~ ,~_---- t~bomestic ^ Fire ^ Other Remarks (Describe deficiencies: bypasses, outlets before the dev(ce, 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 the foregoing data to be correct. ~~.r Lt Print Name f, t,,,, y[ ~; t / f ~,S Certified Tester No. _ 1 Property o ~ ner's ( owner's agent) certification that test was perfoimed: ~ K/ ~?{cliu~t~ Prin Name Title Certification that installation is in accordance with the approved plans. I hereby certify that this installation is in accordance with the approved plans. Name Title License Number Phone ( ) Representing Address City State ZIP Signature g O7'E: SendNotify ownler and wate~ supplier Immedlatelyhf devioo Tailsrtasl andtretpairsn annot containment device at the time of testing ~~~ ~f~t~ F~cpiratlon Date o (~/ ~c ~3/C7 Telephone (To be completed by the design engineer or architect or water supplier.) Date repaired: m M D Y Date m NYS DOH Log # m d y Describe minor installation changes DOH-1013(9/91) NEW YORK STATE DEPARTMENT OF HEALTH Repoet on Test and YVlaintenanco Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180-2216 of Backflow PPevention ®evice ' For the year •~` ~~' Please use a separate form for each device. I 0 Initial test- Complete entire form Annual test-CompletePartAonly Puhlic Water Supply t ' Account No. County ~~ Block Lot 1 Q © lRJ(' N ~~! C~ ~ Location of Device /3 ai ~ \ sue-- ~ ' - ' (,~ Facility Name ` • ~ ' y j Address 1'~l ~ V"v IJ e' ~K E k ~~-~ 11,E ~, `~~ Street lty Zip Device ti f Man facturer ~ `c Type RPZ ~f7CV Model F~~ ~ Size (in inches) ~ Serial Number _ 5 on orma In ,. e( ~ ~ C ck Valve No.1 Check Valve No. 2 Differential Pressure Relief psi Line Pressure Valve Date Test Leaked ~ Leaked ~ Opened at ~ a ~- psid ~ Z. Z ~ 1 3 before Closed tight Closed tight repair P es a drop a cross first check valve M D Y psid - Repaired by Describe Name repairs and materials ~ AApp ~ i : ~ 't i Lic# used fYl ; i t - - ~ "' ,_a Date repaired: M D Y Da te Final test Closed tight Closed tight ^ Opened at psid m M D Y Pressure drop across first check valve psid Water Meter Number Meter Reading Type of Service: (check one) ~1 ~~ v ~~ 7 ~ t ~'' q1 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 i rv ~ meets; U does NOT meet, the requirements of an I hereby certify the foregoing data to be correct. ~ ~. ~ , Print Neme Carliflod Tester No. ~kIM.CS ~llGtl..-5 Property owner' (or owner's agent) certification that test was performed: Pdnt Name Title _ , Certification that installation is in accordance with the approved plans. hereby certify thatthis installation is in accordance with the approved plans. Name Title License Number Phone ( ) Representing Address City State ZiP Signature NOl'L=: Send one comp eted copy to the deslg~ated ealth department representative and one Notify owner and water supplier immediately if device falls test and repairs cannot Date containment device at the time of testing 1 ~ / ~~~ /~ Expiration Date Telephone (To be completed by the design engineer or architect or water supplier.) NYS DOH Log # m d y Describe minor installation changes DOH-1013(9191) ;~. 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 Yest and Maintenance of Backflow Prevention Device C~ni'~ Please use a separate form for each device. """`~' ~ Initial test- Complete entire form 0 Annual test- Complete Part Aonly Publlc Water Supply Account Na. `Co~untyy ". ~ r Block Lot t s( ~ r ~"~4~- '~ ~ L,~11` -~ ~~`~ ~~ ,~ ti E: ~ tC 7 N ilit N F Location of Device /~ l ~ C 1 ~W` ~ ~l'~~ ©~1 ~ t~'1' a me ac y ,01 ~ 1 t ~ f~~ S f`~KlLS ~ e26 ~C7 Jr' ~h(~~ L7~ L~ lai~l~l r r dd ~ . 9 . ress A J Street - qty Zlp Device Manufacturer Type ®RPZ Model ~ Size (in inc es) 3 S,e~riafl Numbed 7`~g~ Information ~ ~S ~CV ~^jQ (~ ~-i Check Valve No.1 Check Valve No.2 Differential Pressure elief Line Pressure psi Valve Test ~ Leaked ~/ Leaked 0 "~ ~ Opened at Je psid Date ~ ~ m before Closed tight t-rJ Closed tight 0 repair ' Pressure drop across first check valve M D Y ~_ psid - Repaired by Describe Name re airs and ~ aterials ~ q wl ~ Q ~ ~ ~" ~ m Lic # used : .~ a ~ i:- , ~, °~; ~ ~ ~-~ Date repaired: .. m m M D Y Final test Closed tight ~ Closed tight ^ Opened at psid Date m M D Y Pressure drop across first checkvaive psid Water Meter Number 11/ f~ ~10 ~-~`'~ Meter Reading Type of Service: (check one) I~Domestic ~ Fire ~ Other Remarks (Describe deficiencies: bypasses, outlets before the dovice, connections belweon the device and point of entry, missing or Inadequate alrgaps, etc.) Certification: This device meets, ~ does NOT meet, the requirements of an acc table containment device at the time of testing I hereby certify the foregoing data to be correct ~,,/ f GI t t5 ~ I ~. ~ --- ~ Print Name Certified Tester No. g ture Expiration Date lt~:r° L: ~lltyc_ Property owner's (or owner's agent) certification that test was performed: ~~e~k~ ~~o~1~p IM pch~,n~~-- r (~Y t~Y63.73/~ Prlnl Name Title Si 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. Title Date NY5 DOH Log # Name License Number Phone ( ) m d y Representing Describe minor installation changes Address City State ZIP signature .... ,_.._ ,.._,:..., a.,,,~,.a -- - oy~ ... ...........~,.~ ---'- NOl'E: Send one completed copy to the designated health department represents vo an one cop DOH-1013(9191) Notify owner and water supplier Immediately if devlco fails test and repairs cannot immediately be ma e. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Flanigan Square, 547 River Street, Room 400 Troy, New York 12180-2216 Repot on Y'esf and iVlain~enance of Backflow t'rrevention ®evice ~~l C Please use a separate form for each device. °' "'°'°°' - ~~~ 0 Initial test- Complete entire form Annual test -Comp/ete Part A only Publlc Water Sup`pl+y t ` - 111 ~0. ifl ~ ~q.~^er Account No. County ~~~ Block Lot 'u~L\` ~y `~ ~ ~ E~` Location of Device C '~ L ~ ~ ~ Facility Name L l \ ~ 1,10( . ®yl C~Eh ~'14,~ ~- Address ,{7~e'~ 1~VIn i+.~lt~7Y~lkl,~S 1"i[l~ ~~15 /~ \ ~C~t~C3e`in2. /7~Ical,~UZ-c'1' 1 S teat Ity Zip Device Manufacturer Type RPZ Modegl C~"Jd" ~ ~xT Size rn in hes) Serial Number Information ~ ~CV I~C/~j-c,.,, ~ Z ~~j Check Valve No. 7 Check Valve No.2 Differential Pressure Relief Line Pressure psi Valve Test Leaked ~ Leaked ~ r Opened at~_psld Date aa before Closed tight Closed tight Q O Z ~ 7 ~ J repair Pressure drop across first check valve M D Y ,~:~, psid Describe _ Repaired by repairs and ~ ` Name materials used Lic# p q ~ Date repaired: ,. x r. m m Fa '., i ~f~ ,a '~, it „ 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 ~ ~ Meter Reading Type of Service: (check one) 1 ~ ~ ~ r""~ ~`~ `~~~ ^ ~ ~ ~ ~LL~ Other . Domestic Fire Remarks (Describe deficiencies: bypasses, outlets before the dovice, connections betwoen the device and point of entry, missing or inadequate airgaps, etc.) t device at the time of testin bl t in e f t i t h ~ ® g a e con a n s o an ace m e requ remen does NOT meet, t meets, Certification: This device I hereby certify the foregoing data to be correct. ~ ~ ~ yy ' , 13 ©I f j,,,~ -L ~ L:`,c.• ratlon Data F~cpl Print Name ~ ~.. rL~, - ~ kyy 5 Certified Tester No. I ature d rf ' ' : orme agent) certification that test was pe s (or o net Property net Print Name Title S' n ure Telephone Ciertlf catlOn that Ir1Stallatl0n IS In aCCO rdance Wlth the approved plans. (To be completed by the design engineer of 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 NOl'E: Send one completed copy to the designated health department representauva and one copy ro me wafer su poet wnnm ou ^ays m use ~esuny uevw°. Notify owner and water supplier Immediately if device fails test and repairs cannot Immediately be ma e. 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 Yest and Maintenance of Backflow Prevention ®evice !~ ~ i `~ Please use a separate form for each device. .,,~ rya, V ~ .. ~- ~ Initial test - Complete entire form Annual test -Complete Part A only Pubtic Water Supply Account No. County Block Lot 1 ~ c.J ~ er- L ~,es5 ~~ ~5 n' ,~~ 11 ~~ ~ ~ ~lJ Facility N a m e Location of Device ~~ ~ ~ (~ ~ ~ i~ / t t ~ Address 1 "`~1.~°L~ l~~' ~ ~l~ i f7~i;/.5 )"'~ (n ~ls ~ ~S p/~ Street City ~ Zip Device Manufacturer Type RPZ Model Size Qn i hes) Serial Number Information ~`~, D~CV G~~ ("1 ~ ~ Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line Pressure psi Valve Test Leaked ~ Leaked 0 ~ Opened at ~. psid Date (~ ~ Z 7 m before Closed tight Closed tight ~ - repair Pressure drop across first check valve M D Y ~_ psid - , , ~~~ Describe ~ ~ ~ Repaired by repairs and ~ i ~ Name materials ~ d ~, ) ~ ~ ' ~ ~ Lic# use ~ ~~V~ ~ =9~~ ' • ; , Date repaired: e~ ~' ~ m m 'i ~:... ~ 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 Meter Reading Type of Service: (check one) h 1' w c ~~.~~ } P Domestic ^ Fire ~ Other Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) tainment device at the time of testing bi o f ~ ~ an acce e c n does NOT meet, the requirements o meets, Certification: This device I hereby certify the foregoing data to be correct (~ 5 r,y t ~ I ? ~l ~ L,i Print Name ~ ~ Lr~kks Certified Tester No, ig ure Expiration Date net's r owner's agent) certification that test was performed: -.,.. Pro a ow / Print Name Title Si elute Telephone CertlflCatlOn that IfIStallatl0n IS In aCCO rdanCe 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 Log # License Number Phone (, ) m d y Representing Describe minor installation changes Address City State Zlp Signature NOl'E; Send one completed copy to the designated eelth department representaavo ane one copy co ma wafer suppuc~ w~un~ ~ ~~ ~ay~ ~~ ~~~_ ~~~~,~,a ~°•~~~• DOH-1013 9/91 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 Vest and fVlaintenance of Backflow Prevention ®evice ~c~ti3 Please use a separate form for each device. ' "'~ ""`"' " ~ Initial test - Complete entire form Annual test-Complete Part Aonly Publlc Water ~SUpply Account No. County Block Lot ~~ lJvl ~Jt o) f ~ ~ ~ ~S y /I ~ t~5 `• ~~~` (''~~ Facilit Name /'~- K., t rb et~ Location of Device A p ~,~k~ 1 ~~"'~p ice" ~C~ }~ ,rt Wh 1 J~ZiI~~ ~ ~dS" ~~ ?~ Address I~P ~ + . Street Il$} Zip Device Information Manufacturer W 11~i~ Type RPZ ~CV Model ~(~ Size (in i ches) ~ '/ Serial Number ~(~ Check Valve No.1 Check Valve No. 2 Differential Pressure Relief Line PrPSSUre psi Valve Test Leaked ~ Leaked ~~ Opened at ~psid Date Z 7 (" ~ before Closed tight Closed tight 0 ,J - repair Pressure drop across first check valve M D Y psid Describe 1 Repaired by repairs and ~ -- - Name materials Lic # used a MAR 11;3 Date repaired: . i'"~ M D Y Final test Closed tight ~ Closed tight ~ Openedat~psid Dafe ~ .~ ~ ~ r Pressure dropp a ross first ~ M D Y check valve t[S~psid Water Meter Number ~ ] ~ Meter Reading Typ of Service: (check one) ~^1 1 ~ VDU i~f~"f Other l ^ Fi n ® ~,~ ~ re Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.) ble containment device at the time of testing t f ~ ® an accep s o does NOT meet, the requiremen meets, Certification: This device I hereby certify the foregoing data to be correct q s ~ ,~ I ~~1~ Print Name ~ l~L - ~ ~~ Cerliflod Tester Na. ign re Expiration Data s (or owner's agent) certification that test was performed: Pro erty owner ' ` ` Print Name T1tIa SI lure Telephone Certlf Catl0n that InStallatl0n 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 NOl'E: Send one complete copy to the deslg~aled health department represen[auvo ane one copy ro ine weiei su~Pum rv,~,,,,, .,~ ~oy~ ~~ •~~~ .~°•..,n --•~_-~ DOH-1013 9/91 Notify owner and water supplier Immed(ately if device fails test and repairs cannot immediately be ma e. t )