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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

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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