How to Fill Out and Submit the NYS Backflow Test Form (DOH-1013)

The NYS backflow test form DOH-1013 is completed by a New York State-certified tester after inspecting a backflow prevention device, and signed copies must be delivered to both the water supplier and the designated health department representative within 30 days of the test.¹ The property owner hires the tester, confirms the form is filled out correctly, and makes sure it reaches the right agencies on time.

When You Need to File One

Under 10 NYCRR Section 5-1.31, a backflow preventer on a public water supply must be tested at installation, after any repair, and once a year after that.² Each of those tests produces its own DOH-1013. Water suppliers track devices in their service area and send notices when an annual test is coming due.

If a device fails, the tester writes the failure on the form and notes the repairs needed. Once the device is fixed, a fresh set of readings goes into the “Final Test” section of the same form. Some water suppliers give you as little as 15 days to complete repairs and retest, but the exact window depends on the local authority.

Identifying Your Device: RPZ or DCV

Near the top of Part A the form asks whether the device is an RPZ (reduced pressure zone) or a DCV (double check valve). Get this wrong and the readings below it stop making sense to the reviewer, because each type has different pass/fail thresholds.

RPZ assemblies have two check valves with a pressure relief valve between them. If back-pressure builds or a check valve fails, the relief valve dumps water rather than letting contamination cross into the supply. They protect high-hazard connections such as chemical plants, hospitals, boiler feeds, and irrigation lines with chemical additives.¹
DCV assemblies use two check valves in series that only let water flow one way. There is no relief valve and no discharge. They fit lower-risk connections such as standard commercial water lines.

RPZ devices sit above ground so the relief valve has somewhere to discharge, which also exposes them to freezing and physical damage. That exposure is a common reason they fail annual tests. If you are not sure which type is on your property, the manufacturer label on the device body will say.

Filling Out Part A

Part A is the tester’s section and does the heavy lifting on the form. For annual tests, it is the only part you need.¹

Header and Device Information

The tester marks the test year and whether the test is initial or annual. The next block identifies the public water supply by name, the customer account number if available, and the county. Properties in the New York City metropolitan area also need the block and lot number.

The facility section takes the property name, full street address, and where the assembly sits inside the building, such as a meter room or basement mechanical closet. Below that go the device manufacturer, type (RPZ or DCV), model number, size in inches, and serial number. Every entry has to match the physical label on the device. A mismatched serial number is one of the fastest ways to have the report kicked back.¹

Test Before Repair

This is the mechanical heart of the form. The tester notes whether check valve #1 leaked or closed tight, then does the same for check valve #2. For RPZ devices, two pressure readings decide the outcome:

Check valve #1 pressure drop must be at least 5.0 psid. A reading below 5.0 means the check valve is not holding enough back-pressure and the device fails.
The relief valve opening point must be at least 2.0 psid, or the device fails and needs repair.¹

The tester also records water system line pressure in psi and the date of the test. DCV assemblies have no relief valve, so that row stays blank and only the check valve readings apply.

Repairs and Final Test

If the initial readings failed, the tester or a certified repairer describes the repairs, lists the materials used, and enters the repairer’s name, license number, and repair date. The “Final Test” section then takes a fresh set of readings from after the repair. If nothing needed fixing, leave this section blank.

Service Information, Remarks, and Signatures

Near the bottom, the tester records the water meter number and reading and identifies the type of service. For connections that do not fit a standard category, an “other” field takes a description such as boiler feed, irrigation line, or fire suppression. The remarks area is for deficiencies or observations worth flagging, like physical damage or access problems that could complicate future tests.

The tester checks a box indicating whether the device meets requirements, prints their name, signs, and enters their certified tester number and its expiration date. Without those credentials the form is invalid.¹ The property owner or the owner’s agent signs as well, certifying the test was performed on their device.

When Part B Applies

Part B is only for initial installations, and it is completed by the design engineer, architect, or water supplier rather than the tester. It collects the professional’s name, title, license number, phone number, company, and address. The professional signs and dates the form and indicates which reviewing authority (NYSDOH or the local health department or water supplier) approved the installation. Any minor changes from the original installation plan get described here.¹ For annual retests, ignore this section.

Confirming the Tester Is Certified

Only individuals holding a valid certification under 10 NYCRR Section 5-1.31 can legally perform these tests in New York State.³ Before the tester arrives, verify their certification number is current through the NYS Department of Health or your local health department. An expired certification makes the whole DOH-1013 invalid, and you would have to pay for another test with a properly certified professional. The tester should be using a differential pressure gauge calibrated to NIST-traceable standards within the past year.⁴ Testing fees typically run from roughly $150 to $350 per device, depending on device type, size, and how accessible the assembly is.

Submitting the Completed Form

The form’s own instructions are explicit. Send one completed copy to the designated health department representative and one copy to the water supplier within 30 days of the test.¹ The tester keeps a copy for their records, and the property owner should keep one too, which means a properly distributed form generates at least four copies.

How you submit depends on your water supplier. Some accept scanned copies by email or through a dedicated online portal; others still want paper by mail. In New York City, the Department of Environmental Protection runs an electronic submission system for backflow test forms. If you mail a paper copy, use a method with delivery confirmation, because a missing form and a never-sent form look identical to the reviewing authority. Contact your water supplier directly to confirm the preferred submission method and the correct address or portal.

Keeping Your Own Records

The regulation places the formal record obligation on the water supplier, stating that “records of such tests shall be made available to, reviewed by, and maintained by the supplier of water.”² No numerical retention period is specified. Even so, hold onto your own copies of past DOH-1013 reports for several years. If a dispute comes up over whether a test happened, or an inspector questions your compliance history, your copies are the proof. Water suppliers sometimes misplace paperwork, and the practical burden of showing compliance falls back on the property owner when that happens.

What Happens If You Skip It

Missing the annual test or failing to submit the DOH-1013 puts the property at risk of losing water service. New York City’s Department of Environmental Protection warns that failure to perform the required annual test could result in fines or disconnection of water service.⁵ Other water suppliers across the state have similar enforcement authority, since the state regulation requires them to maintain an active cross-connection control program.

1
New York State Department of Health. DOH-1013 Report on Test and Maintenance of Backflow Prevention Device
2
New York State Regulations. N.Y. Comp. Codes R. and Regs. Tit. 10 5-1.31 – Cross-Connection Control
3
New York State Department of Health. Certified Backflow Testers
4
Branom Instrument Co. Backflow Test Kits
5
NYC Department of Environmental Protection. Backflow Prevention Devices