Doh 1013 Form PDF Details

Ensuring the safety and quality of public water supplies is a critical responsibility that involves regular testing and maintenance of backflow prevention devices. In New York State, this responsibility is underscored through the use of the DOH 1013 form, a comprehensive document mandated by the New York State Department of Health Bureau of Public Water Supply Protection. This form serves as a detailed report on the testing and maintenance activities carried out on backflow prevention devices, which are essential in preventing the reverse flow of water from potentially contaminating the public water supply. The form is structured into two main parts: Part A, which must be completed by a certified tester for both initial and annual tests, detailing the device's location, specifications, testing results before and after repairs, and final certification of the device's compliance. Part B is reserved for the design engineer, architect, or water supplier for initial tests, providing certification that the installation matches the approved plans. The document also includes sections for detailing deficiencies, making repairs, and certifying the accuracy of the provided information. By requiring the completion and submission of the DOH 1013 form, the New York State Department of Health ensures that each backflow prevention device is functioning correctly, protecting the community's health and safety by maintaining the purity of its water supply.

QuestionAnswer
Form NameDoh 1013 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnys doh 1013 form, doh form 1013, doh 1013 test and maintenance form, doh 1013 pdf

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection Empire State Plaza - Corning Tower Room 1110 Albany, NY 12237

Report on Test and Maintenance of Backflow Prevention Device

 

 

 

 

Please use a separate form for each device.

 

 

 

 

For the year ______________________

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test

Leaked

 

 

 

 

 

 

 

 

 

 

 

 

 

Leaked

 

 

 

 

 

Opened at _______ psid

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before

Closed tight

 

 

 

 

 

 

 

 

 

 

 

Closed tight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

repair

Pressure drop across first check valve

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

D

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______ psid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Repaired by

repairs and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name __________________

materials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

used

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lic # ___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date repaired:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

D

 

Y

Final test

Closed tight

 

 

 

 

 

 

 

 

 

 

 

Closed tight

 

 

 

 

 

Opened at ______ psid

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pressure drop across first

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

D

 

 

Y

 

 

 

 

check valve ______ psid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Water Meter Number

 

 

 

 

 

 

 

 

 

 

 

Meter Reading

 

 

 

 

Type of Service: (check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9 Domestic

 

 

9 Fire

9 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.

1013(9/91)

Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made.

 

 

 

 

DOH-

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 ΑTest Before Repair≅and indicate:

C

Whether check valve #1 leaked or closed tight. For RPZ devices, the pressure drop accross the check

 

valve must be at least 5.0 psid.

CWhether check valve #2 leaked or closed tight.

COpening of RPZ differential pressure relief valve - must be at least 2.0 psid or device must be failed and/or repaired.

CComplete water system line pressure in psi and indicate test date.

#Describe any repairs and materials used and the name and license number of the repairer and indicate repair date.

#Complete Αfinal test≅section only if repairs have been made.

#Indicate the water meter number/meter reading and the type of service (describe Αother≅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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Part number 1 in filling in form 1013 doh

2. Once your current task is complete, take the next step – fill out all of these fields - Describe repairs and materials used, Repaired by, Name, Lic, Date repaired M D Y Date, M D Y, Final test, Closed tight, Closed tight, Opened at psid, Pressure drop across first check, Water Meter Number, Meter Reading, Type of Service check one, and Remarks Describe deficiencies with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

The right way to complete form 1013 doh portion 2

3. In this specific stage, have a look at Property owners or owners agent, PART B, Certification that installation is, To be completed by the design, I hereby certify that this, Name, License Number, Representing, Address, City, Title, Phone, Date, m d y, and Describe minor installation changes. Each of these will need to be filled out with utmost precision.

form 1013 doh conclusion process detailed (part 3)

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