Report On Test And Maintenance Of Backflow Prevention Device Form (Page 2 of 2) in pdf

Report On Test And Maintenance Of Backflow Prevention Device Form Page 2

INSTRUCTIONS FOR COMPLETING SCWA FORM 215B

REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE

Suffolk County law 37-2011 dictates NYS Certified Testers be a licensed master plumber or employed by

a licensed master plumber who is also a certified backflow tester. In addition, both parties must be

registered with Suffolk County Consumer Affairs to perform backflow testing.

This form must be signed by all parties (master plumber, certified tester, owner/agent) as

well as all Licensing/Registration Numbers Completed or it will be returned unprocessed.

INITIAL TEST ONLY: NYS DOH 1013 will be accepted. Parts A & Part B must be completed by

the installer and design engineer or architect.

Complete SCWA Contract Account #, Facility Name, address and specific location of device (i.e.

first floor, meter room, Hot Box, etc)

Complete device information inclusive of manufacturer, type, model, size and serial number

Complete Section “Test Before Repair” and indicate

Whether check valve # 1 leaked or closed tight. For RPZ device, the pressure drop

across the 1

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 pressure in psi and indicate test date

Describe any repairs and material used and the name and license number of the repairer and

indicate repair date.

Complete “final test” section only if repairs were made.

Indicate water meter # (if inside meter) and type of service

Complete Remarks Section if applicable

Complete the certification portion

Complete Master Plumber’s Name, Licensing Jurisdiction, Master Plumber License #

Complete Master Plumber’s Consumer Affairs Backflow #

Master Plumber’s signature

Backflow Tester’s Consumer Affairs Registration #, NYS Certification # and signature

Have owner or owner’s agent print/sign to certify test was performed

215B / march13

Report On Test And Maintenance Of Backflow Prevention Device Form Page 2