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r f <br /> NEW YORK STATE DEPARTMENTOFHEALTH <br /> Bureau of Public Water Suppty Protection Report on Test and Maintenance <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 /> PAR A I-1 Initial test- Complete entire form <br /> II Annual test-Complete Part A only <br /> Public Water Supply Account No. County Block Lot <br /> ra l IC / Location of Device <br /> Facility Name l ��`� �JALt `1 ,/�ll�,tln\ 1 �f�q/ {^,�(�`-s ( (� <br /> Address A Mcv,,1;-\(‘,,VNAA ���'A \\ �\' m v`/�CJ� &LA Gam' `Q ©� �C7mAfi--� <br /> Street City' <br /> Device Manu cture��� C Type r1RPZ MAeel Size(in inches) Serial Number <br /> Information I PCV 2.. ,4-7`16' •-c4 <br /> -i <br /> heck Valve No.1 Check Valve No.2 Differential Pressure Relief Line Pressure Is-0 psi <br /> Valve <br /> Date <br /> Test Leaked Leaked I I Opened at n psid -11 �I <br /> before Closed tight Closed tight <br /> repair <br /> Pressure 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: <br /> 1 <br /> M D Y I <br /> Date <br /> Final test Closed tight y Closed tight �4�/ Opened at psid �� (T6I <br /> Pressure drop: oss first MD IV <br /> check valve(/! psid <br /> Water Meter Number Meter Reading Type of Service:(check one) <br /> 0 Domestic 0 Fire tt Other <br /> Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc) <br /> Certification:This device SMeets, does NOT meet,the requirements of an ac ptable tainment de ice at the time of testing <br /> I herebyrgrtify tri foregoing data to be torr �j � <br /> it�' I''!c7 l2 r. Vin 1-Q r I���K.�-�' `�j> I <br /> Name Certified Tester No. Signature Expiration Date <br /> Property owner's(or owner's agent)certification that test was performed: <br /> Print Name Title Signature Telephone <br /> PART B Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water <br /> supplier.) <br /> I hereby certify that this installation is in accordance with the approved plans. — <br /> Name Title Date I I I NYS DOH Log# <br /> License Number Phone( ) m d y <br /> — <br /> Representing Describe minor installation changes <br /> Address <br /> City 1 State I 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(9/91j <br />