Form Doh-1013 - Report On Test And Maintenance Of Backflow Prevention Device

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NEW YORK STATE DEPARTMENT OF HEALTH

Report on Test and Maintenance

Bureau of Public Water Supply Protection

Empire State Plaza - Corning Tower Room 1110

of Backflow Prevention Device

Albany, NY 12237

For the year ______________________

Please use a separate form for each device.

PART A

Initial test - Complete entire form

Annual test - Complete Part A only

Public Water Supply

Account No.

County

Block

Lot

Location of Device

Facility Name ______________________________________________

_____________________________________________________

Address___________________________________________________

_____________________________________________________

Street

City

Zip

Device

Manufacturer

Type

RPZ

Model

Size (in inches)

Serial Number

Information

DCV

Check Valve No. 1

Check Valve No. 2

Differential Pressure Relief

Line Pressure ________psi

Valve

Date

Leaked

Opened at _______ psid

Test

Closed tight

before

repair

Pressure drop across first check valve

______ psid

Repaired by

Describe

Name __________________

repairs and

materials

Lic # ___________________

used

Date repaired:

Date

Closed tight

Opened at ______ psid

Final test

Pressure drop across first

check valve ______ psid

Water Meter Number

Meter Reading

Type of Service: (check one)

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,

does NOT meet, the requirements of an acceptable containment device at the time of testing

I hereby certify the foregoing data to be correct.

______________________________________ ____________________________ __________________________

______/_____/_______

Print Name

Certified Tester No.

Signature

Expiration Date

Property owner=s (or owner=s agent) certification that test was performed:

_______________________________________ ____________________________ __________________________

(____)_____-________

Print Name

Title

Signature

Telephone

PART B

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 installation changes

Address

City

State

Zip

Signature_____________________________________

NOTE: Send one completed copy to the designated health department representative and one copy to the water supplier within 30 days of the testing device.

Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made.

DOH-

1013(9/91)