Report on Test and Maintenance of Backflow Prevention …

NEW YORK STATE DEPARTMENT OF HEALTHB ureau of Public Water Supply ProtectionEmpire State Plaza - Corning Tower Room 1110 Albany, NY 12237 Report 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_____DeviceInformationManufacturer Type RPZ DCVM odelSize (in inches)Serial NumberCheck Valve No. 1 Check Valve No. 2 Differential Pressure ReliefValveLine Pressure _____psi Leaked Closed tightTestbeforerepairPressure drop across first check valve_____ psid Leaked Closed tight Opened at _____ psidDate M D Y Describerepairs andmaterialsusedRepaired byName _____Lic # _____Date repaired: M D YClosed tight Final testPressure drop across firstcheck valve _____ psidClosed tight Opened at _____ psidDate M D YWater Meter NumberMeter ReadingType of Service: (check one)9 Domestic 9 Fire 9 Other_____Remarks (Describe deficiencies: bypasses, outlets before the device, connections between the device and point of)

REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE PART A - To Be Completed by Certified Tester # Indicate the test year and whether initial or annual test. # Complete public water supply name, customer account number (if available) and county. # Complete block and lot (if available) for New York City Metropolitan area tests.

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