Get Nys Doh Form For Report On Test And Maintenance Of Backflow Prevention Device

This guide provides a step-by-step approach to completing the New York State Department of Health Form for the Report on Test and Maintenance of Backflow Prevention Device. By following these instructions, you will ensure that all required information is accurately submitted online.

Follow the steps to fill out the Nys Doh Form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Indicate the year for which the test is being reported and select whether this is an initial test or an annual test by checking the appropriate box.
3. Complete the public water supply information, including the account number (if available), county, block, and lot numbers (if applicable).
4. Enter the facility name, and specify the location of the backflow prevention device, including the complete street address.
5. Provide device information, including the manufacturer, type (RPZ or DCV), model, size in inches, and serial number.
6. Complete the 'Test Before Repair' section: indicate if check valve #1 and check valve #2 leaked or closed tightly, and report the line pressure and date.
7. Describe any repairs made, including the name and license number of the person who performed the repairs, along with the repair date.
8. If repairs have been made, fill out the 'Final Test' section and indicate the water meter number and type of service.
9. Detail any deficiencies in the remarks section, such as bypasses or inadequate air gaps.
10. In the certification section, confirm if the device meets or does not meet the requirements, print your name, certificate number, signature, and expiration date.
11. Have the property owner or their agent certify that the test was performed.
12. If completing Part B, the design engineer, architect, or water supplier must fill out their details, sign, and date the form.
13. After completing the form, save changes, download a copy, print it, or share the form as necessary.

Complete your Nys Doh Form for Report on Test and Maintenance of Backflow Prevention Device online today.