Gen215B Form PDF Details

The Gen215B form, integral to maintaining the integrity of New York City's public water supply, serves as a comprehensive report on the test and maintenance procedures of containment backflow prevention assemblies. This document is a requisite tool employed by the NYC Department of Environmental Protection (DEP) to ensure that the water supply remains uncontaminated by potential backflows. The form caters to various scenarios, including initial tests for newly installed assemblies and annual tests for existing ones, thus requiring meticulous completion of its multiple parts by different certified professionals. Part A, which needs to be filled out in all cases, captures basic information about the facility and the backflow prevention assembly. Part B is tailored for NYS certified backflow prevention assembly testers, detailing the assembly's operational metrics and any repairs undertaken. In situations warranting initial testing, Part C demands the expertise of a NYS licensed professional engineer or registered architect to certify the installation's compliance with approved plans. Finally, Part D requires a NYC licensed master plumber's certification, ensuring the assembly adheres to the Building Department's requirements. Together, these sections work in tandem to fortify NYC’s water system against contamination, highlighting the form's pivotal role in safeguarding public health.

QuestionAnswer
Form NameGen215B Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesgen215b, gen215b dep, nyc dep gen 215b, gen 215b

Form Preview Example

*If YES, please explain in detail in the space provided or on an additional paper.

NYC-DEP

Form for Report on Test and Maintenance of Containment Backflow Prevention Assembly

Bureau of Water and Sewer Operations

Please use a separate form for each assembly

Part A- TO BE COMPLETED IN ALL CASES

Initial Test

Complete entire form

Annual Test – For the Year ______.

Complete Parts A & B Only

Public Water Supply: NYC-DEP

County:

 

Block:

 

 

Lot:

 

 

Department Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name & Address of Facility:

 

 

 

Make & Model # of Assembly

 

 

 

___________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________

 

 

 

 

 

 

 

Size & Serial # of Assembly

 

 

 

___________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location (Floor) of Assembly:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B- TO BE COMPLETED BY NYS CERTIFIED BACKFLOW PREVENTION ASSEMBLY TESTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure

 

Check Valve No. 1

Check Valve No. 2

 

Differential Pressure

 

Line Pressure ______ psi

 

 

Relief Valve (RPZ only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pressure drop across first

 

 

 

 

 

 

 

 

 

 

 

Test Before Repair

check valve, psi ______

Leak

(

 

)

Opened at ______ psi

 

Date: ______/______/______

 

 

 

 

Closed tight

(

 

)

 

Leak

(

)

 

 

 

 

 

 

 

 

 

 

Closed tight

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Repairer:

Describe repairs,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parts and materials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name, Lic. # & Seal of Master Plumber.

used.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Repair: _____/_____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pressure drop across first

 

 

 

 

 

 

 

 

 

 

 

Final test

check valve, psi ______

Closed tight

(

 

)

Opened at ______ psi

 

Date: ______/______/______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Closed tight

(

)

 

 

 

 

 

 

 

 

 

 

 

Water Meter Number:

Meter Reading:

Completion Time of

 

 

 

Type of Water Service/System (Please Check One):

 

 

 

 

 

Test (e.g. 3:15 pm):

 

 

 

( ) 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 ( )

CERTIFICATION: This assembly meets the requirements of an

 

CERTIFICATION: This assembly does NOT meet the requirements.

acceptable containment assembly at time of testing.

 

 

 

 

I hereby certify the foregoing data to be correct.

 

 

 

 

___________________________________

____/____/____

 

___________________________________

____/____/____

 

 

Signature

Date

Signature

Date

 

 

 

 

 

 

_________________________________

(____)______-_________

______________________________

____/____/____

PRINT NAME

Telephone No.

 

Certified Tester No.

Expiration Date

Part C- TO BE COMPLETED BY NYS PE OR RA

Professional Engineer’s or Registered Architect’s Certification:

I have personally checked this installation and I certify that it is in accordance with the approved plans.

NYC-DEP Backflow Prevention

Assembly Approval #:

[ ] I am the Designer of Record. [ ] I am NOT the Designer of Record.

PE/RA Printed Name:

___________________________________________

Company:

___________________________________________

Address:

___________________________________________

Telephone #:

___________________________________________

Signature, Seal & Date:

 

Minor Installation Changes (describe): (Attach additional sheets if required)

Part D – TO BE COMPLETED BY NYC LICENSED MASTER PLUMBER

Master Plumber’s Certification: [ ] I am [ ] I am NOT the Licensed

Master Plumber of Record. I have personally checked this installation and I certify that it is in accordance with the Building Department’s Requirements.

Building

Department

Number:

(Use Sticker)

Plumber’s Printed Name:

______________________________________

Plumber’s License #:

______________________________________

Telephone #:

______________________________________

Signature, Seal and Date:

 

NOTE: Send one completed form, within 30 days of installation and initial testing, with original ink signatures and original ink or impressed seals to NYC-DEP-BWSO, Cross-Connection Control Unit, 59-17 Junction Blvd., 3rd Fl. Low-Rise, Flushing, NY 11373

NYC - GEN215B

Rev 1/2019

INSTRUCTION FOR COMPLETION OF

“Report on Test and Maintenance of Containment Backflow Prevention Assembly”

(FORM GEN215B)

Use a separate form for each particular assembly

Indicate Initial Test or Annual Test by checking the appropriate choice.

Initial Test and Certification: Complete all 4 parts.

Annual Test/Re-Certification: Complete parts A and B only

Please follow these tips to have the form completed:

Part A: To be completed in ALL cases for the current address, block and lot #s, the tested BFP assembly (make, model # in full, size and serial #) and actual location of the tested assembly (floor/level, vault, hot box) along with a specific location (meter/boiler/pump room, store, garage, etc.), if any.

Part B: NYS Certified Backflow Prevention Assembly Tester shall fill out this portion in ALL cases:

Include the line pressure (taken at number 1 test cock with shutoff valve number 1 closed).

Include the pressure drop across the first check valve (the pressure differential between the second and the third test cocks).

Include the condition of check valves # 1 and 2.

Describe repairs, parts and materials used, replacement of assembly and details of procedures. If any, complete final test.

Indicate the water meter # (8 digits) and reading.

Completion time of test refers to the time of day (e.g. 8:00 am) and test date.

Check actual type of the water service/system (Internal Water Main “IWM”).

Be sure to answer (check) Question 1. If the answer is “YES”, explain in the space provided. A connection for a properly installed and certified parallel assembly should not be construed as a connection. Hose cocks and spigots shall be considered as connections. Tees/ells shall be removed completely and hard pipe. Cross-connections upstream of the assemblies are prohibited except otherwise allowed and approved for the parallel assemblies’ installations.

Then, clearlyprint, type or rubber stamp: Date, Name, Phone #, Certified Tester # and Certified Tester Expiration Date.

Part C: Complete for Initial Test Report only!

The NYS Licensed Professional Engineer or Registered Architect (PE/RA) shall complete Part C. Be sure to fill in the following:

The “NYC-DEP Backflow Prevention Assembly Approval #”.

Indicate whether being the designer of record or not.

Indicate minor changes, if any. Use back or additional pages as required. Indicate “See Back” or “See Additional Pages” as appropriate. If an equivalent make and model # of assembly is used, the PE or RA shall certify that the submission is acceptable and will not cause any adverse hydraulic effects on the water system. Also satisfy the submersion calculations (for RPZ/RPD assemblies only, if installed below grade level).

If the installation changes meet DEP requirements while deviating from the approved plans, the job shall be resubmitted for re-approval or an as-built plans shall be submitted to legalize the on-site condition/discrepancy.

When the installation deviates from the approved plans and minimum requirements are not satisfied, the job should NOT be certified.

Part D: NYC Licensed Master Plumber shall complete Part D. Be sure to fill in the following:

Indicate whether being the Licensed Master Plumber of record or not

The Department of Buildings Number (ARA #, ALT #, NB #, LAA #, etc.). Use of sticker is preferred.

Licensed Master Plumber’s Name.

Licensed Master Plumber’s License #.

Licensed Master Plumber’s Telephone Number.

Original Ink Signature, raised impression Seal of Licensed Master Plumber & Date.

Notes: The PE/ RA, Licensed Master Plumber & Certified Tester shall sign the same form for each particular assembly. For each completed form, USE ORIGINAL INK SIGNATURES & ORIGINAL INK OR RAISED IMPRESSION SEALS. Mail one completed form to: NYC- DEP-BWSO

Cross-Connection Control Unit

59-17 Junction Boulevard, 3rd Fl. Low-Rise, Flushing, NY 11373-5108

Refer to “NEW YORK CITY CROSS-CONNECTION CONTROL PROGRAM HANDBOOK”, latest version on DEP web site.

NYC - GEN215B

Rev. 1/2019 | DCN: BWSO-FRM-1-2019

How to Edit Gen215B Form Online for Free

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example of gaps in dep gen 215 test report form

Enter the demanded details in the area Closed tight, Meter Reading, Water Meter Number, Type of Water ServiceSystem Please, Completion Time of Test eg pm, other deficiencies NO YES If, CERTIFICATION This assembly meets, CERTIFICATION This assembly does, acceptable containment assembly at, Signature, Date, Signature, Date, PRINT NAME, and Telephone No.

stage 2 to finishing dep gen 215 test report form

It's essential to put down certain information in the section PERA Printed Name, Company, Address, Plumbers Printed Name, Telephone, Plumbers License, Signature Seal Date, Telephone, Minor Installation Changes describe, Attach additional sheets if, Signature Seal and Date, NOTE Send one completed form, NYCDEPBWSO CrossConnection Control, and Rev.

dep gen 215 test report form PERA Printed Name, Company, Address, Plumbers Printed Name, Telephone, Plumbers License, Signature Seal Date, Telephone, Minor Installation Changes describe, Attach additional sheets if, Signature Seal and Date, NOTE Send one completed form, NYCDEPBWSO CrossConnection Control, and Rev fields to fill out

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