Report on Test and Maintenance of Backflow Prevention …

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NEW YORK STATE DEPARTMENT OF HEALTHBureau of Public Water Supply ProtectionEmpire State Plaza - Corning Tower Room 1110Albany, NY 12237Report on Test and Maintenanceof Backflow Prevention DevicePART APlease use a separate form for each the year ______________________ Initial test - Complete entire form Annual test - Complete Part A only Public Water SupplyAccount Name ________________________________________ ______Address___________________________ ________________________ Street City ZipLocation of Device__________________________________ ________________________________________ ________________________________DeviceIn formationManufacturerType RPZ DCVModelSize (in inches)Serial NumberCheck Valve No. 1Check Valve No.

Report on Test and Maintenance of Backflow Prevention Device PART A ... PART B Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water ... # Complete section ATest Before Repair@ and indicate: C Whether check valve #1 leaked or closed tight. For RPZ devices, the ...

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