Form Doh-1013 - Report On Test And Maintenance Of Backflow Prevention Device Page 2
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2INSTRUCTIONS 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.
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Complete public water supply name, customer account number (if available) and county.
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Complete block and lot (if available) for New York City Metropolitan area tests.
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Complete facility name, address and specific location of device (e.g., meter room, etc.)
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Complete device information including manufacturer, type, model, size and serial number.
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Complete section ATest Before Repair@ and indicate:
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Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
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valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
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Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
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and/or repaired.
Complete water system line pressure in psi and indicate test date.
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Describe any repairs and materials used and the name and license number of the repairer and indicate repair
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date.
Complete Afinal test@ section only if repairs have been made.
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Indicate the water meter number/meter reading and the type of service (describe Aother@ e.g., boiler feed,
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irrigation line, etc.)
Complete the Remarks section if there are any deficiencies.
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Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
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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.
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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.
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Sign and date form and indicate NYSDOH (or local health department/water supplier).
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Describe minor installation changes.
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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
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