HomeMy WebLinkAbout2021-08-13 DOH RPZ Backflow Prevention Device TestingNEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Public Water Supply Protection
Report on Test and Maintenance
of Bacldlow Prevention Device
For Iha year (-0) \
i@fj Please use 11 separate form for each device.
cm lnttial test • Complete entire form
D Annual test • Complete Part A only
Account No. County lock Lot
Cc, (.JC. (
Faclllty Name Le, ki._,\l \ i.\J \\e c.\-\k <:~~ ,..\J\ ct_i Location~! Dav fr ................. ::H:s?.0. ... : ....... 0..tl.L .................................................. .
Address '?f:l·····}:J .. <;.§i± .... .Cc:<.Y..\':'J. .. ~ ...... \:\.h.r"~··"'··..l'f/··/..Y.f°.!;.c.' 41-e(~ /Zc•,,.._ .... !..~ ..................................................................................................... ..
Line Pressure S' 7 psi
Closed tight Opened at ~' C,, psid Date lolril []] Im
Pressure dro~?Cross first
check valve _ZJ_ psid
m d y
Repaired by
Name _______ _
lie 11 _______ _
Date repaired OJ DJ OJ
m d y
Closed tight c:J
Pressure drop across first
check valve psid
Closed tight c:J Opened at ___ psid Date rnrnrn
Water Meter Number 7o clo& <flf
Meter Reading .... ~·o
TY!fS of Service: (check one)
r£1 Domestic 0 Fire 00thef
m d y
Remarks (Describe deffdencies: bypa!i.Ses, outlets before the device, connections between the device and point or entry, missing or Inadequate mroap, etc.)
Certttication: This device meets. D does NOT meet, the requirements of an acceptable containment device at the time of testing
I hereby cartify the foregoing data to be correct
\c\v, C:r11 wAn Zc 31
Print Name Certified Tester No-. Expiration Date --··-. -----:;,l..------------"---'--'--"----"--==---1 Property owner's (or owner's agent) certification that test was performed:
... ff'.~:":::1
•••••••••••• e.c:.:~t:J.:.!.::::..:-2........................... . ............ :-S.~""'11~.-:~~.-,\,,, .............................. .
Print Name Title
.~./2-. SiQn~ture ............................................... .
i@i:ii Certfflcation that installation is In accordance with the approved plans. (To be completed by Ille design anginear or architect ___ _ or water suppller.)
I hereby certlliy that this Installation has been made in accordance with the approved plans.
!'-N_am_• ___________ -+=-n-111e ___________ --; Date ITJ m ITJ
j License Number Phone ( m '-iJ' y
NYSDOH Log#
j Representing Describe minor installation changes
i"Adci;;;~· .. ··· ... ... .................... ... . .. ... ... . . . ..... . . . . . . .. . . .. . ..... .
[ciiY ....................................... ··· ··· ···T5;;;r;; .. ···· ···· · ... . ··y2;;;·· . .. . . .. . ...... .
Signature _______________ _
NOTE: Send on& completed copy to the designated health department representatlVe and one copy to the water suppl1ar within 30 days of testing of the OOvh::&.
DOH·1013 (9191) Notify owner and water suppller Immediately If device falls test and repairs cannol lmmedlately be ma<:le.
WHITE • OFFICE COPY YELLOW · CUSTOMER COPY PINK • NYS DEPARTMENT OF HEALTH
NEW YORK STATE DEPARTMENT OF HEAL TH
Bureau of Public Waler Supply Protection
Report on Test and Maintenance
of Bacldlow Prevention Device
For the year 'J-0 J-\
•@i1 Please use 11 separate loim for each device.
12£1 Initial test • Compfete entire form
D Annual test -Complete Part A only
Supply Account No. County
Co,'(VCi h
Block lot
Faclllty Name l.A.7\ \\.-(\) \ e.,\ i \\.f' c,\'\\, ';,,-t r·\I i C ·u loqijlon o~e v r\-
.•...• .1;;;?.<::~C,. ......... \J.0.l .. : ............................... ···························
Address ·z'?..?. .... ~::-J .. ::."'~: .... C:.,;;is-:.t.\ ... '::~~ ...... \\hr.:.\-i, .... .IY•:f. ..... tt.fS...9. ..... . 11'1-<:.J:J, 0 •:c:, I" ............................... ~ ...................... _.,., .......................................... ..
street city ,;p
line Pressure '?7 psi
Closed tight Opened at /), f psid Date ~ [ill Im]
Pressure dror:i across first
check valve [~_L psid
m d y
Repaired by
Name _______ _
Uc# _______ _
Date repaired DJ DJ DJ
m d y
Closed tight c:J
Pressure drop across first
check valve __ . _ psid
Closed tight Opened at ___ psid Date rnrnrn
Water Meter Number
1o c;;c,t/Cf
Meter Reading
ooo'Jlo
TYP,11 of Service: (check one)
r!2I' Domestic 0 Fire 00ther
m d
Remarks (Describe O&fldenci&s: bypasses, ouUets before the device, coonectJons bet'WE!en the device and point or entry, mis.sing or Inadequate alfOap, etc.)
y
Certttication: This device meets, D does NOT meet, the requirements of an acceptable containment device at the time of testing
. . I hereby certify the. foregoing data to be co'.rect., ! .
)o\'-"" (TU·. \C\.-\0 zc;, $ J... &/1..•"J ~ 12 IS t 1J,1,
Print Name Certified Tester No. .SiQnature ExpiratiOn Date --·--· ~'.~£:;.;::~:~:?~~::::~g;~t).:.:i'.ic~t,~~.~.:11:,:::.~~ .. =~~'.=:~:········ ...... ;Z .. ;.e=~'················· !..Eh~~! .. ~~°.r..: .. z.~.z~
Print Name Tiiie Signature Telephone
i@i:i Certttication that installation is In accordance wtth the approved plans. (To be completed by Iha design engina<lr or architect
...,,.,_..... ... _ or water suppher.)
I hereby certttiy that this Installation has been made in accordance wtth the approved plans.
,_lN_am_•-----------+-1i-1t1e __________ --l Date rn m rn
j Uoonsa Number Phone ( m (r' y
i.~.~P.'.".5."~.ti.°.11............................................................................................................................... Describe minor installation changes
iAddress !ciiY······························· ············ · ···· ···F~;;;;; ····· · · ····· · · · ·· Tzi;; ·· · · · · · ··· · ·· ·
Signature
NYS DOH Log#
NOTE: Sand one compktte-0 copy to the de!llgnaled heaJth department reproseniattve and one copy to the water supplier wi!:hln 30 days of testing of !he devle&.
DOH-l013 (9191) Notify owner and water supplier Immediately II device falls test and repairs cannot lmmedlatety be made.
WHITE .. OFFICE COPY YELLOW · CUSTOMER COPY PINK · NYS DEPARTMENT OF HEALTH