GEN215B
COMPANY
*
PAR
AWS
FIELD / OFFICE
*
FIELD
OFFICE
CHOOSE YOUR NAME
*
Please Select
BS
GL
JB
LMH
MM
PC
PM
RD
SR
TI
XX
WO#
*
JOB#
*
SCOPE
LOCATION
*
ADDRESS
*
CITY
*
STATE
*
ZIP
*
COUNTY
*
Please Select
BRONX
BROOKLYN
MANHATTAN
QUEENS
STATEN ISLAND
BLOCK
*
LOT
*
TEST TYPE
*
ANNUAL
INITIAL
LMP CERTIFICATION
I AM NOT THE INSTALLING LMP
I AM THE INSTALLING LMP
DEP APPROVAL #
INITIAL TEST ONLY
DOB PERMIT #
INITIAL TEST ONLY
YEAR DUE
4 DIGITS
DEVICE STATUS
*
EXISTING
NEW
REPAIR
REPLACEMENT
MAKE
*
Please Select
AMES
APOLLO
BACKFLOW DIRECT
CLA-VAL
CONBRACO
FEBCO
WATTS
WILKINS
ZURN
MODEL
*
SIZE
*
Please Select
1/2"
3/4"
1"
1-1/4"
1-1/2"
2"
2-1/2"
3"
4"
6"
8"
10"
12"
SERIAL #
*
OLD SERIAL #
LOCATION OF DEVICE
*
FLOOR - ROOM - AREA
TEST BEFORE REPAIR
TEST DATE
/
Month
/
Day
Year
Date Picker Icon
LINE PRESSURE
*
PSI
CHECK VALVE #1 PRESSURE DROP
PSI
CHECK VALVE #1
*
LEAK
CLOSED TIGHT
CHECK VALVE #2
*
LEAK
CLOSED TIGHT
DIFFERENTIAL PRESSURE RELIEF VALVE (RPZ ONLY) OPENED AT
LEAK
EXTRA NEEDED FOR REPAIRS
INFO NEEDED FOR EXTRA
REPAIRS
DESCRIBE REPAIRS, PARTS, MATERIALS USED
CHECK VALVE #1 REPAIRS
CHECK VALVE #2 REPAIRS
DIFFERENTIAL RPZ REPAIRS
REPAIRER NAME
Please Select
BRIAN SINGLE
GARY LONG
JAMES BARBERA
MUHAMMAD MIAN
PAUL CRONE
PAUL MEZZATESTA
ROBERTO DRUDI
TAOFIQ IBRAHIM
REPAIR - LJL INFO
Please Select
LAWRENCE J LEVINE, 161
FINAL TEST
FINAL TEST DATE
*
/
Month
/
Day
Year
Date Picker Icon
CHECK VALVE #1 PRESSURE DROP
PSI
FINAL CHECK#1
CLOSED TIGHT
FINAL CHECK#2
CLOSED TIGHT
DIFFERENTIAL PRESSURE RELIEF VALVE (RPZ) OPENED AT
PSI
WATER METER #
*
METER READING
*
SERVICE TYPE
*
DOMESTIC
FIRE
COMBINED
IWM
QUESTION #1 - ARE THERE ANY CONNECTIONS BETWEEN THE POINT OF ENTRY AND THE BACKFLOW PREVENTION ASSEMBLY, OR OTHER DEFICIENCIES?
*
NO
YES
QUESTION #1 RESPONSE
TIME
*
Hour Minutes
AM
PM
AM/PM Option
TESTER SIGNATURE
*
UPLOAD PHOTOS
*
TAKE A PIC OR UPLOAD
Drag and drop files here
Choose a file
BACKFLOW SERIAL#, METER#, MODEL INFO
Cancel
of
TESTER
*
Please Select
BRIAN SINGLE
GARY LONG
JAMES BARBERA
MUHAMMAD MIAN
PAUL CRONE
PAUL MEZZATESTA
ROBERTO DRUDI
TAOFIQ IBRAHIM
CERT #
*
Please Select
7848
6706
5757
13756
6617
13460
6618
9493
EXPIRATION - MONTH
*
EXPIRATION - DAY
*
EXPIRATION - YEAR
*
Email
*
example@example.com
PREVIEW PDF
SAVE + FINISH LATER
SUBMIT
BILL TO
BILL TO ADDRESS
BILL TO CITY
BILL TO STATE
BILL TO ZIP
CONTACT NAME
CONTACT EMAIL
SIGNATURE TEST - DAY
2 DIGITS - TODAY'S TEST DATE
CONTACT #
**CONTACT # copy
SIGNATURE TEST - MONTH
2 DIGITS - TODAY'S TEST DATE
**TEST DATE COPY1
SIGNATURE TEST - YEAR
2 DIGITS - TODAY'S TEST DATE
**SERVICE TYPE COPY
**SIZE COPY
**COUNTY COPY
**MAKE COPY
**FINAL TEST COPY
**TESTER COPY
**DEVICE STATUS COPY
SIGNATURE DATE
*
/
Month
/
Day
Year
Date Picker Icon
**CHECK#1 COPY
**CHECK#2 COPY
**FINAL CHECK#1 COPY
**FINAL CHECK#2 COPY
**TEST - MONTH
**TEST - DAY
**TEST - YEAR
2 DIGITS
Should be Empty: