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NEWYORK STATE ARTMENT OF HEALTH Report on Test and Maintenance <br /> Bureau of PubliccWater Water Supply Protection <br /> Flanigan Square,547 River Street,Room 400 <br /> Troy,New York 12180-2216 of Backflow Prevention Device <br /> Please use a separate form for each device. For the year <br /> Initial test- Complete entire form <br /> Annual test-Complete Part A only <br /> Public Water Supply Account No. County Block Lot <br /> Facility Name <br /> Location of Device <br /> J i1.1Q <br /> Addressr� , V�JkQ - <br /> Street City Zip <br /> Device foanufaqturer Type =RPZ Model Size(in inches) Serial Number <br /> Information � <br /> ,� Q'c" , t( l / �lo3G <br /> Check Valve No.1 Check Valve No.2 Differential Pressure Relief Line Pressure psi <br /> Valve <br /> Test Leaked Leaked Opened at psid Date I—�— <br /> before Closed tight Closed tight <br /> repair Pressure drop drop across first check valve M D Y <br /> psid <br /> Describe Repaired by <br /> repairs and Name <br /> materials <br /> used <br /> Lic# <br /> Date repaired:: �l l <br /> LTJ [I__J <br /> M D Y <br /> Final test Closed tight Closed tight FQ, Opened at�Zpsid Date <br /> K- 4-� 71T] ELI <br /> Pressure dro a ross first M D Y <br /> check valve sid <br /> Water Meter Number Meter Reading Type of Service:(check one) <br /> ❑Domestic ❑Fire h-< Other_ <br /> Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc.) <br /> Ce A cation:This device 1:1 meets, 0 does NOT meet,the requirements of an a able con"Ifime evice at the time of testing <br /> I hereby th f regoing data to be cw /l 7 <br /> 1� t <br /> Name Certified Tester No. ure Expiration Date <br /> Property owner's(or owner's agent)certification that test was performed: <br /> Print Name Title Signature Telephone <br /> rrebyCertification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water <br /> supplier.) <br /> ify that this installation is in accordance with the approved plans. <br /> Name Title Date NYS DOH Log# <br /> License Number Phone( ) m d y — <br /> Representing Describe minor installation changes <br /> Address <br /> City State Zip <br /> Signature <br /> 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. <br /> Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made. DOH-1013(9/91) <br />