Form DOH-1013 "Report on Test and Maintenance of Backflow Prevention Device" - New York

What Is Form DOH-1013?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 1991;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOH-1013 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-1013 "Report on Test and Maintenance of Backflow Prevention Device" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
Report on Test and Maintenance
Bureau of Public Water Supply Protection
Empire State Plaza - Corning Tower Room 1110
of Backflow Prevention Device
Albany, NY 12237
For the year ______________________
Please use a separate form for each device.
PART A
Initial test - Complete entire form
Annual test - Complete Part A only
Public Water Supply
Account No.
County
Block
Lot
Location of Device
Facility Name ______________________________________________
_____________________________________________________
Address___________________________________________________
_____________________________________________________
Street
City
Zip
Device
Manufacturer
Type
RPZ
Model
Size (in inches)
Serial Number
Information
DCV
Check Valve No. 1
Check Valve No. 2
Differential Pressure Relief
Line Pressure ________psi
Valve
Date
Leaked
Leaked
Opened at _______ psid
Test
Closed tight
Closed tight
before
repair
Pressure drop across first check valve
M
D
Y
______ psid
Repaired by
Describe
Name __________________
repairs and
materials
Lic # ___________________
used
Date repaired:
M
D
Y
Date
Closed tight
Closed tight
Opened at ______ psid
Final test
M
D
Y
Pressure drop across first
check valve ______ psid
Water Meter Number
Meter Reading
Type of Service: (check one)
9
9
9
Domestic
Fire
Other__________________
Remarks
(Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device
meets,
does NOT meet, the requirements of an acceptable containment device at the time of testing
I hereby certify the foregoing data to be correct.
______________________________________ ____________________________ __________________________
______/_____/_______
Print Name
Certified Tester No.
Signature
Expiration Date
Property owner=s (or owner=s agent) certification that test was performed:
_______________________________________ ____________________________ __________________________
(____)_____-________
Print Name
Title
Signature
Telephone
PART B
Certification that installation is in accordance with the approved plans.
(To be completed by the design engineer or architect or water
supplier.)
I hereby certify that this installation is in accordance with the approved plans.
Name
Title
Date
NYS DOH Log #
____________________
License Number
Phone (
)
m
d
y
Representing
Describe minor installation changes
Address
City
State
Zip
Signature_____________________________________
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.
Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made.
DOH-
1013(9/91)
NEW YORK STATE DEPARTMENT OF HEALTH
Report on Test and Maintenance
Bureau of Public Water Supply Protection
Empire State Plaza - Corning Tower Room 1110
of Backflow Prevention Device
Albany, NY 12237
For the year ______________________
Please use a separate form for each device.
PART A
Initial test - Complete entire form
Annual test - Complete Part A only
Public Water Supply
Account No.
County
Block
Lot
Location of Device
Facility Name ______________________________________________
_____________________________________________________
Address___________________________________________________
_____________________________________________________
Street
City
Zip
Device
Manufacturer
Type
RPZ
Model
Size (in inches)
Serial Number
Information
DCV
Check Valve No. 1
Check Valve No. 2
Differential Pressure Relief
Line Pressure ________psi
Valve
Date
Leaked
Leaked
Opened at _______ psid
Test
Closed tight
Closed tight
before
repair
Pressure drop across first check valve
M
D
Y
______ psid
Repaired by
Describe
Name __________________
repairs and
materials
Lic # ___________________
used
Date repaired:
M
D
Y
Date
Closed tight
Closed tight
Opened at ______ psid
Final test
M
D
Y
Pressure drop across first
check valve ______ psid
Water Meter Number
Meter Reading
Type of Service: (check one)
9
9
9
Domestic
Fire
Other__________________
Remarks
(Describe deficiencies: bypasses, outlets before the device, connections between the device and point of entry, missing or inadequate airgaps, etc.)
Certification: This device
meets,
does NOT meet, the requirements of an acceptable containment device at the time of testing
I hereby certify the foregoing data to be correct.
______________________________________ ____________________________ __________________________
______/_____/_______
Print Name
Certified Tester No.
Signature
Expiration Date
Property owner=s (or owner=s agent) certification that test was performed:
_______________________________________ ____________________________ __________________________
(____)_____-________
Print Name
Title
Signature
Telephone
PART B
Certification that installation is in accordance with the approved plans.
(To be completed by the design engineer or architect or water
supplier.)
I hereby certify that this installation is in accordance with the approved plans.
Name
Title
Date
NYS DOH Log #
____________________
License Number
Phone (
)
m
d
y
Representing
Describe minor installation changes
Address
City
State
Zip
Signature_____________________________________
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.
Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made.
DOH-
1013(9/91)
INSTRUCTIONS FOR COMPLETING DOH-1013 (9/91)
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.
#
Complete facility name, address and specific location of device (e.g., meter room, etc.)
#
Complete device information including manufacturer, type, model, size and serial number.
#
Complete section ATest Before Repair@ and indicate:
#
Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check
C
valve must be at least 5.0 psid.
Whether check valve #2 leaked or closed tight.
C
Opening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed
C
and/or repaired.
Complete water system line pressure in psi and indicate test date.
C
Describe any repairs and materials used and the name and license number of the repairer and indicate repair
#
date.
Complete Afinal test@ section only if repairs have been made.
#
Indicate the water meter number/meter reading and the type of service (describe Aother@ e.g., boiler feed,
#
irrigation line, etc.)
Complete the Remarks section if there are any deficiencies.
#
Complete the certification indicating if the device meets or does not meet the requirements at the time of testing -
#
print and sign your name and indicate certificate number and expiration date.
Have the property owner (or owner=s agent) certify that test was performed.
#
PART B - To Be Completed By Design Engineer, Architect or Water Supplier for initial Tests Only
Complete name, title, license number, phone number, company name and address.
#
Sign and date form and indicate NYSDOH (or local health department/water supplier).
#
Describe minor installation changes.
#
After completion, submit copies of test reports to the supplier of water, customer, State or local heatlh department and
retain copies for the tester=s personal records.
Revised 12/93
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