Nyc Dep Gen 215B Details

Maintaining accurate, up-to-date contact information is essential for any business. Employees move, phone numbers change, and email addresses get updated. All of this contact information needs to be captured in some form or another. For many businesses, the Gen215B form is the go-to tool for capturing contact data. This simple form can help businesses keep track of all their contacts in one place. It's easy to use and can be customized to fit your specific needs. Plus, it's always up-to-date with the latest changes in contact information.

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QuestionAnswer
Form NameGen215B Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 215b, gen215b, nyc dep gen 215b form, backflow preventer test report form

Form Preview Example

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: ______/______/______

Leak

(

)

Closed tight

(

 

)

 

 

 

 

 

 

 

 

 

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

 

 

 

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 FORCOMPLETION OF

Report on Test and Maintenance of Containment Backflow Prevention Assembly

(FORMGEN215B)

Use a separate form for each particularassembly

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

InitialTestandCertification:Completeall4parts.

AnnualTest/Re-Certification:CompletepartsAandBonly

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.

Indicatethe watermeter# (8 digits) andreading.

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

Checkactualtypeofthewaterservice/system (Internal Water Main “IWM”).

Besuretoanswer(check) Question1. Iftheansweris“YES”, explaininthespaceprovided. Aconnectionforaproperlyinstalledand 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,typeorrubberstamp:Date,Name,Phone#,CertifiedTester#andCertifiedTesterExpirationDate.

Part C: Complete for Initial Test Report only!

TheNYSLicensedProfessionalEngineerorRegisteredArchitect(PE/RA)shallcompletePartC. 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. Ifan equivalent make and model # of assembly is used, the PE orRA 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 whetherbeingtheLicensedMasterPlumberofrecordornot

TheDepartment of Buildings Number(ARA #,ALT #,NB #,LAA#,etc.). Useofstickerispreferred.

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. Mailonecompletedformto: NYC-DEP-BWSO

Cross-Connection Control Unit

59-17JunctionBoulevard,3rdFl. Low-Rise, Flushing,NY11373-5108

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

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