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HomeMy WebLinkAboutReport on Test and Maintenance of Backflow Prevention Device 2025 NEW YORK STATE DEPARTMENT OF JE Report on Test and Maintenance Bureau of Public Water Supply ProtectionMARI of Backflow Prevention Device For the year VILLAGE OF RYE BROOK ) Initial test Complete entire form Pleas u ! '+seiiate`taf�lti-fo ' �_�levice. Ri�Annual test - Complete Part A only Public Water Sypply � �� Account No. CountyBlock Lot 6[16( Facility Name c1ty Location of Device � ,G� _......-.. .. ..................................... ................. ..................._....... AddressIt.... .{....... ..,........ .....do.P`..!...1._.. ..© .... L� '...t...l................................................................. street r.6ty zip Device Manufacturer Type VD_V �)rcrw PZ odel Size (in inches) Serial Number Information rlt INN60 Choi*Valve No. 1 j Check Valve No.2 DH dal Pressure / fl otYaly® Line Pressure psi Test Leaked 0 Leaked ❑ Opened at psid Date before Closed tight Closed tight repair Pressure drop acr ss first m d y check valve j• psid Desulbe Repaired by repairs and Name materials Lic tt used Date repaired [I] m m m d y Final test > Closed tight ❑ � � m Pressure drop across first Closed tight ❑ Opened at psid Date check valve psid m d y Water MWX Meter Reading Type of Service: eck one) ❑ Domestic Fire ❑Other Remah(s (oescnbe deficiencies:bypasses,outlets before The device,connections t)etween the device and point of entry,missing or inadequate airgap,etc.) Certification:This device meets, ❑ does NOT meet,the requirements of an acceptable contai ent device at the time of testing I hereby y the lore oing data to be correct. nt N� Certifie Tester No. gignature Expiration Date Property owner's(or owner's agent)certification that test was performed'. ........... ...T...�6 4, .................. ner........................ . ............................ l Prrnt Name Title Sig tur Telephone Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby cerlifiy that this installation has been made in accordance with the approved plans. Name Title Date m m 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 testing of the d"c•. DOH-1013(9191) Notify owner and water supplier immediately if device fails test and repairs cannot Immediately be made. WHITE-Water Purveyor CANARY-Health Dept. PINK-Property Owner(Non-Transferable) GOLD-File Copy