Report On Test And Maintenance Of Backflow Prevention Device Form
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2SUFFOLK COUNTY WATER AUTHORITY
REPORT ON TEST AND MAINTENANCE
OF BACKFLOW PREVENTION DEVICE (215B)
4060 Sunrise Hwy/PO BOX 38
Oakdale NY 11769
For the Year________
(631) 563-0266 (Ph) (631) 218-1145 (Fax)
_____Annual Test
A separate form must be completed for each device
SCWA CA # _______________________________
PLEASE NOTE: INCOMPLETE FORMS WILL NOT BE PROCESSED AND RETURNED TO THE CUSTOMER
Location of RPZ/DCV
Facility Name
_____________________________________________________
________________________________________
_____________________________________________________
Address
_____________________________________________
Street
City
Zip
Device Information
Manufacturer
RPZ____
Model
Size (in inches)
Serial Number
DCV____
Check Valve No 1
Check Valve # 2
Differential Pressure
Line Pressure ____psi
Relief Valve
Test before repair
Leaked_____
Leaked ______
Opened at _____psid
Date Tested (m/d/y)
Closed Tight _____
Closed Tight ______
_____/______/______
st
Pressure drop across 1
check valve ______psid
Describe repairs &
materials used
Repaired by
Name_______________
Lic # ________________
Date Repaired
_____/_______/______
Final test
Closed tight _____
Closed tight _______
Opened at ______psid
Date (m/d/y)
_____/______/_______
st
Pressure drop across 1
check valve ________
Water Meter #
Meter Reading
Type of Service: (check one)
Domestic_____ Fire _______ Irrigation _______ Other________
Remarks: Describe deficiencies, bypasses, outlets before device, connections between device and point of entry, missing/inadequate air gaps
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
__________________________ ______________
________ __/__ /
________________
_______________________________
Backflow Tester Name (Print)
NYS Cert # Exp Date
Consumer Affairs #
Signature
_________________________________________
________ __/__/____ ________________
________ ______________________
Master Plumber’s Name (Print)
NYS Cert # Exp Date
Consumer Affairs #
Signature
___________________________________ _____ ____________________
Licensing Jurisdiction
License #
_______________________________________ ______________________________________ _
__________________
Customer’s name (Print)
Signature (Certification that test was performed)
Phone #
NOTE: Send one completed copy to the designated health department representative and one copy to SCWA within 30 days of test. Notify
owner and SCWA immediately if device fails test and repairs cannot immediately be made.
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