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DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF WATER & SEWER OPERATIONS

REVISED SUPPLEMENT TO THE NEW YORK STATE DEPARTMENT OF HEALTH HANDBOOK FOR CROSS CONNECTION CONTROL

This supplement was last revised on (6/10)

Introductory Note:

This supplement will help you prepare backflow prevention plans for submittal. It is a guide only and should not be used as a substitute for experience in the planning and design of backflow prevention device installations. If you are not experienced with this type of work, we suggest that you consult with a professional.

To avoid the expense and delay necessitated by the removal and reinstallation of containment devices, we suggest that you have your plans approved by DEP before proceeding with installation.

For new facilities, aesthetic considerations and architectural design is an unacceptable reason for granting exemptions. The architectural design must accommodate the containment devices, not the other way around.

Please note that the filing Professional Engineer or Registered Architect is expected to review the potential for hazard posed by the occupancy of the premises.

Based upon this review, the filing Professional Engineer or Registered Architect should select an appropriate containment device in accordance with the latest revision of the DEP Cross Connection Control Risk Assessment.

Page 1

Rev. 06/10

OVERVIEW OF THE NYC ENVIRONMENTAL PROTECTION

CROSS-CONNECTION CONTROL PROGRAM

For the Protection of the Water Supply System by Containment

WHO IS AFFECTED

Owners of properties that pose an actual or potential risk of contamination to New York City’s water supply. This includes property with any of, but not limited to, the following facilities:

BAKERY	AUTO BODY / REPAIR SHOPS
BIDETS	BEAUTY SALONS OR BARBER SHOPS
CAR WASH	BUTCHERS (INCLUDES FISH MARKETS & LIVE STOCK)
CHEMICALS USED IN PROCESSING e.g.	CHEMICALLY TREATED BOILERS
DYE PLANTS, PHOTO LABORATORIES
COMMERCIAL LAUNDRY FACILITIES WITH 2 OR MORE COIN	DRY-CLEANING ESTABLISHMENTS
OPERATED MACHINES
DELICATESSEN /PREMISES WHERE FOOD IS BEING PREPARED	COMMERCIAL KITCHENS / RESTAURANTS
DENTAL OFFICES /LABORATORIES	LARGE BOILERS (MORE THAN 350000 BTU)
DISTILLED BREWERIES	BOOSTER PUMPS
FUNERAL PARLORS	HOTELS AND/OR MOTELS
GREENHOUSES	GAS STATIONS AND/OR MINI MARTS WITH SODA MACHINES OR
	COFFEE LINES
IN-GROUND IRRIGATION SPRINKLER	HEAT EXCHANGERS WITH WATER (SINGLE WALL)
WELLS (GROUNDWATER)	PHARMACY
MULTIPLE WATER SERVICES	PRESSURE TANKS
SEWAGE TREATMENT OR HANDLING	PRIVATE WELLS
VETERINARY OFFICES / LABORATORIES	SWIMMING POOLS / COMMERCIAL SWIMMING POOLS
WAREHOUSES (WITH TOXIC CHEMICALS STORAGE)	METAL MANUFACTURING, CLEANING, PROCESSING OR
	FABRICATING PLANTS
WATER REUSE / RECYCLING	WATER COOLED EQUIPMENT OR CHILLERS
MEDICAL OFFICES / LABORATORIES	WATER STORAGE TANKS
(INCLUDES PSYCHOLOGY & PSYCHIATRIC OFFICES THAT
ADMINISTER MEDICATION)

WHAT LAW REQUIRES

Owners must install special plumbing devices, known as a backflow prevention device(s) on the water service pipes that supply their property. The device prevents water from flowing back into the City’s drinking water supply. Owners must obtain the approval of plans submitted to the Department of Environmental Protection (DEP) before installing the device and have the device tested by a state certified backflow-prevention device tester at least once a year. DEP’s Bureau of Water and Sewer Operations is charged with enforcing Part 5 Section 5-1.31 of the State Sanitary Code and Title 15, Chapter 20 of the Rules of the City of New York (RCNY).

HOW TO COMPLY

Step 1: A Professional Engineer (PE) or Registered Architect (RA) must prepare and submit two sets of plans and two applications originals (form GEN-236 New York City Version) for the installation of Backflow Prevention Device(s) to the Bureau of Water and Sewer Operations, Division of Permitting and Inspections for approval. All submissions must have original ink signatures and original ink or impression seals. Plans and applications must be corrected and resubmitted as necessary until acceptable.

Step 2: When the plans are approved, the Division of Permitting and Inspections issues a plan approval letter to the customer and returns one copy of the approved plans to the PE or RA of record.

Step 3: The device(s) must be:

Installed by a New York City Licensed Master Plumber in accordance with the approved plans (installations must also meet the Building Department’s and the Bureau of Customer Service’s requirements).

Tested by a State Certified Backflow Prevention Device Tester who is either a Licensed Master Plumber or employed by one. Inspected by a PE or RA and certified that they have found the installation to be in accordance with the approved plans.

Step 4: Finally, a completed “Report on Test and Maintenance of Backflow Prevention Device” (form GEN-215B), certifying the job, must be submitted to DEP within thirty days of installation of the device.

Step 5: Annual Inspection: At least once a year, the device must be inspected, maintained and tested, by a state certified tester. The results of the test must be reported to the department by filing Form GEN 215B with parts A & B properly completed.

Note: Be aware that some plumbers may provide “Turn Key” installation.

Page 2

Rev. 06/10

If you believe that your premise does not require a Backflow Prevention Device, you may have a Professional Engineer, Registered Architect, or Licensed Master Plumber submit a request for Exemption to the DEP Cross Connection Control Unit for consideration. If approved an exemption letter will be issued.

Steps for Installing Backflow Prevention Device

The following steps must be taken for the preparation, submission and approval of plans and the installation of backflow prevention devices for CONTAINMENT of facilities:

Step 1: A Professional Engineer (PE) or Registered Architect (RA) must prepare and submit two sets of plans and two applications originals (form GEN 236 New York City Version) for the installation of Backflow Prevention Device to the Bureau of Water and Sewer Operations, Division of Permitting and Connections for approval. All submissions must have original ink signatures and original ink or impression seals. Plans and applications must be corrected and resubmitted as necessary until acceptable.

Step 2: When the plans are approved, the Division of Permitting and Connections issues a plan approval letter to the customer and returns one copy of the approved plans to the PE or RA of record.

Step 3: Device(s) must be:

•	Installed by a New York City Licensed Master Plumber in accordance with the approved
	plans (installations must also meet the Building Department’s and the Bureau of Customer
	Service’s requirements)
•	Tested by a State certified Backflow Prevention Device Tester who is either a Licensed
	Master Plumber or employed by one
•	Inspected by a PE or RA and certified that they have found the installation to be in
	accordance with the approved plans.
Step 4:	Submit the “Report on Test Maintenance of Backflow Prevention Device” (Form GEN
	215B), certifying the job to DEP within thirty days of device installation.

DEP will refer improper installations to the owner, PE or RA, or both. Improper installations must be corrected and re-certified (with Form GEN 215B) until acceptable. All installations are subject to inspection and verification.

Page 3

Rev. 06/10

Guidelines for Filling out Proposal of Backflow Prevention Device(s) Installation

General:

Provide two sets of plans and two GEN 236 application forms bearing the original signature and seal of the applicant.

All services of the same facility shall be protected and listed on the application.

Backflow Prevention (BFP) Device(s) shall be NYS – DOH approved.

No strainers are allowed between the water meter and the device. If required, strainer shall be approved type installed on the street side of the meter.

No take offs are allowed on the street side of the device except approved combined services.

Piping to be unbranched and unrestricted from main to device except for meter.

The device shall be installed between the meter and the meter test tee.

Meter test tee shall be capped or plugged.

For RPZ and RPD devices where the proposed installation has to be below grade (i.e. Cellar or Basement), the applicant shall provide time calculations for full device failure up to the submersion of device discharge port. The time shall exceed 8 hours; otherwise, device(s) shall be installed above grade.

Need to provide Elevation Plan, Floor Plan, Plot Plan, Engineering Report and notes.

Floor Plan

Show a minimum of 30 in. clearance from the side of the device to the farthest wall or obstruction.

Show a minimum of 8 in. clearance from the side of the device to the closest wall or obstruction.

Show size of the meter.

Plan view showing every BFP in conjunction with the water meter, test tee, meter inlet control valve (MICV) and meter outlet control valve (MOCV).

Drainage details for RPZ’s must be shown.

Elevation Plan:

Provide a minimum of 30 in. clearance space from the centerline of device to floor.

Provide a maximum of 60 in. clearance space from the centerline of device to floor.

Provide a minimum clearance of 12 in. from the device to the ceiling.

Air gap between the RPZ’s relief port and the drain must be:

2 in. air gap for device size of ¾ in. to 1 in.

3 in. air gap for device size of 1 ¼ in. to 1 ½ in. 4 in. air gap for device of 2 in. or larger

If there is no gravity drainage, device shall be installed above grade. Sump Pump is not acceptable for gravity drainage.

Plot Plan:

Show north arrow

Show the size of water service

Site plan for the entire facility must show the closed property line and labeling or all water service lines, mains, streets, location of BFP.

Notes:

Print the drainage area in sq. ft. if you are installing in the basement or the cellar.

If the BFP is installed more than 60 in. from the centerline above the floor, an OSHA approved platform, scaffold or ladder must be provided for maintenance and testing.

Between point of entry and BFP, the pipes must be stenciled “FEED TO BACKFLOW PREVENTER, DO NOT TAP OR CONNECT TO THIS LINE.” at 5 ft intervals, and at all wall and floor penetration

Page 4

Rev. 06/10

APPLICATION FOR APPROVAL OF BACKFLOW PREVENTION DEVICES

[] FEE: $350 PER SERVICE CONNECTION

PRINT OR TYPE ALL ENTRIES EXCEPT SIGNATURES

0. Block #

0a. Lot #

FOR DEPARTMENT USE ONLY

Please complete items 0 through 13.

Name of Facility:

2. County:

0b. Tentative Lot #

Exact Location of Facility; i.e., Street Address:

3a.

City

3b.

State

3c. Zip

4. Contact Person:

4a.

Phone Number(s):

New York

Location of Device(s): (Attach additional sheets if required)

6. Manufacturer,

Model No.

and Size of Device(s):

5a. # of Fire Services:

5b. # of Domestic Services:

5c. # of Combined Services:

5d. Total # of Services:

5e. Total # of Buildings:

Name, Title & Phone No. of Property Owner:

Type of Submission

[

]

As Built

[

]

Initial Device Installation

Full Mailing Address:

[

]

Replace Existing Device

8a.

[

] New Service

[

]

Existing Service

8b.

[

] New Building

[

] New Extension

[

] Major Renovation

Owner's Signature:

Date:

[

]

Existing Building

Print Name and Address of Design Engineer or Architect:

10.

NYS License #:

[

] PE [ ] RA

[ ] Other

10a.

Telephone #:

10b.

FAX #:

10c.

Date:

Original Ink Signature & Seal Required on both copies.

11.

Water System Pressure (psi) at Point of Connection:

12. Estimated Installation cost:

10d.

EMAIL:

Max _________ Avg _________

Min _________

13.

Degree of Hazard:

List of Processes or reasons which lead to degree of hazard checked:

[

] Hazardous

[

] Non-Hazardous with Hazardous Fixtures

[

] Aesthetically Objectionable

14.

Public Water Supply Name:

NEW YORK CITY

Name of Supplier's Designated Representative:

Selim Andrawis, P.E.

Mailing Address:

NYC - DEP

Title:

Engineer-In-Charge

Bureau of Water & Sewer Operation

Cross-Connection Control Unit

The degree of hazard shown in (13) above is in corformity with the latest DEP

3rd Floor Low-Rise

Cross Connection Control Risk Assessment

59-17 Junction Boulevard

Flushing, NY 11373

Telephone No.: (718) 595-5463

Signature:*

Date:

Facsimile No.: (718) 595-5252

* Your signature endorses proposal

NOTE:

Two copies of this form and two copies of all plans, specifications and supporting materials must be submitted to:

New York City,

Department of Environmental Protection, Bureau of Water & Sewer Operations,

Cross-Connection Control Unit, 3rd Floor Low-Rise, 59-17 Junction Boulevard, Flushing, NY 11373.

Gen236 NYC version 3/11

INSTRUCTION FOR FORM GEN 236 (NYC VERSION)

APPLICATION FOR APPROVAL OF BACKFLOW PREVENTION DEVICES

0 to 4a) Fill in as appropriate. Be sure to include the block and lot numbers.

5)Be as specific as possible. (e.g. “8’ N of Elm Street and 12’ South of Main Street”)

5a, b, c) Fill in the number of services for the entire facility.

5d)	This is the total of 5 a, b, and c.
5e)	Fill in the total number of buildings in the facility. All adjacent buildings under the same
	ownership, occupancy or operation are considered part of the facility. Distant buildings with the
	same water, heating or other shared, common or interconnected systems are considered part of

the same facility. If you have doubts or uncertainties, feel free to elaborate at length on additional sheets.

6)Note Manufacturer, model & size of each device.

7)Indicate name, mailing address & phone number of property owner. Be sure this information is current. Failure to provide correct property owner mailing address will result in delayed notification.

Be sure to use original ink seal & signatures on both originals.

8, a, b) Check the applicable boxes

9)Print name & company (if any) of the design engineer or architect. (Do not use the name of the firm in place of the P.E.’s or R.A.’s name). Fill in the complete mailing address.

Be sure to use original ink seals & sign on both originals.

10)Include NYS License number in blank. Check appropriate category.

10 a, b) Be sure to enter all applicable phone/fax numbers.

10c)	Enter date application is signed.

11)Make sure that water system pressure at point of connection is included.

12)Be sure to include these estimates. No blanks permitted. Use fair market value if you are working for free.

13)Choose one of the Degree of Hazard and list the reasons. If you decided to choose Double Check Valve Assembly (DCVA), you are required to give the proper reasons.

14)To be completed by Water Supplier.

If you need additional space, use the back or attach additional sheets. If so, please indicate “Continued on back” or “See Additional Sheets” as appropriate.

Page 6

Rev. 06/10

Cross Connection Control Unit	Review Form for BFP Plan
59-17 Junction Boulevard, 3Fl. Low Rise, Flushing, NY 11373-5108
To: ________________________________			Re:____________________________________
__________________________________________			Address: ___________________________________________
__________________________________________			___________________________________________
			Block:____________Lot:________________County: _________
* We are sending you: □Plans	□Samples	□Gen 236	□Other _____________________________
□DISAPPROVED		□RETURNED FOR ADDITIONAL INFORMATION

COMMENTS

□ 2 sets of plans & 2 copies of GEN 236 application forms required (Original)

□Drawings must be of acceptable standard quality & easily legible

□Require PE / RA’s signature and stamp/seal (original) on every Application Form (NYC, GEN236-# 9), every Plan and also the Engineering Report (if any)

□Need to provide Plot Plan (for the entire lot), Elev. Plan, Floor Plan, and Notes

□Provide Elaborated Eng. Report: Bldg. description, type of business, general use of water service(s) within facility, brief description water supply system, etc.

□Pipes to be disbranched & unrestricted from main to device except for meter.

□No strainers are allowed between Water Meter and BFP. If required, Strainer should be approved type (Flat Plate) and installed on street side of the Meter.

□No take offs are allowed on the street side of the BFP (although installation of BFP’s in parallel is allowed)

□Pipes not installed within 2 feet of device must be exposed and be readily accessible for inspection

□Need address of building on plan (every submitted drawing)

□Require labeling all items, (either existing or new) in the drawings

□Leave adequate space for NYC-DEP-CCCU approval stamps.

□ Show state (exist./new), size, type, single make, and model # of device on

plans

□Show state (existing/new) of all items on the drawings

□“RPZ” & “DCV” devices must be of the same size as the water meter or larger

□Show the clearances and direction of flow, on the Elevation and Plan views

□Every submitted drawing must have Block, Lot, & County indicated

□From point of entry inside the facility, House Control Valve should be installed within 2 feet, and Water Meter should be installed within 5 feet

□BFP must be installed between the Master Meter and Meter Test Tee

□Meter Test Tee, MICV and MOCV must be located near the water meter and installed within the same meter room with the HCV. MOCV must be installed on the HOUSE SIDE of test tee. 1.5” Test Tee is required for water meters 1.5” size or larger and it must be CAPPED

□For water meters larger than 2”, 5x and 3x Dia. of pipe must be maintained before and after the Meter respectively.

□Calculate time for full device failure to submersion of device discharge port (detailed), it must exceed 8Hrs. Otherwise device must be installed above grade

□All service lines (existing or new) of the same facility (s) in the same lot must be protected and listed on one application

□Backflow Prevention must be NYS-DOH approved, adequately supported, have shutoff valves on both ends (as one assembly) and indicated on the drawings

□Other _____________________________________________________

FLOOR PLAN

□Show the 30” Min. clearance space from front side of device to the farthest

wall or any obstruction

□Show the 8” Min. clearance space from back side of device to the closest wall or any obstruction

□Show the state (existing or new), size &S.# of the meter(s) & all sub meters if any

□Bypass on “DCDA” & “RPDA” devices must be shown to specify clearances

□Bypass around the “BFP” is not acceptable, unless similar BFP is provided

□Show every BFP in conjunction with the Water Meter, Meter Inlet Control Valve (MICV), Meter Test Tee, and Meter Outlet Control Valve (MOCV)

□Drainage details for RPZ & DCV must be shown. How will water be disposed of?

□Other _______________________________________________

_______________________________________________

Elevation Plan

□Provide the 30” Min. Clearance space from centerline of device to floor

□Provide the 60” Max. Clearance space from centerline of device to floor

□Air gap between the RPZ’s relief port and the drain must be Minimum of:

2” – for device size of 0.75” to 1” 3” – for device size of 1.25” to 1.50” 4” – for device size of 2” or larger

□Have clearance >12” from highest point of device to the ceiling or obstruction

□Show the Grade Level and how far from the Floor of device

□Sump pump is not acceptable for “RPZ” installations except if Emergency Power Supply is provided

□If there is no gravity drainage, “RPZ” device must be installed above grade

□Other _____________________________________________________

NOTES

□Print the drainage area in sq. ft. if “RPZ” is installed below Grade Level

□If the BFP is installed more than 60” from centerline (or highest point of Device if vertical), to above finished floor, an OSHA approved platform, and scaffold or ladder must be provided for maintenance and testing.

Height above finished floor for platform should be between 24”-66” to handle

□Between point of entry & BFP, the pipes must be stenciled “FEED TO BFP, DO NOT TAP OR CONNECT TO THIS LINE” at 5’ intervals, at all wall & floor penetrations

□Fire Service(s) must be protected with “BFP” Device

□Fire service(s) must be protected with “RPDA” if there are provisions for chemicals (antifreeze, rust-inhibitors) to be used

□For multi stores/addresses Bldg., all facilities (exist. or new) must be specified and addressed, showing all water meters and sub-meters (if any) to each of the occupancies (tenants)

□Other _____________________________________________________

PLOT PLAN

□Show / verify North arrow on the Plot Plan

□Show / verify the size of water service(s)

□Site plan for the entire facility (lot) showing the closed property line & labeling all water service lines (exist. & new), mains, streets, and location of BFP

□Other__ ___________________________________________________

GEN236 (Application Form)

□Need to fill all the blanks from items 0 to 13

□Need the property owner’s name and signature (original) on item # 7only

□Lack original ink signatures and stamps on both copies

□Have missing / incorrect entries for certain fields

□Valid reason must be given in box 13 Gen 236 form when facility is rated as aesthetically objectionable, and “DCV” is proposed for installation:

1.No defined risk present/anticipated

2.Non Hazardous- Complex Plumbing Fixtures

□Other _____________________________________________________

_____________________________________________________

THESE ARE MINIMUM REQUIREMENTS. PLANS WILL BE REJECTED IF INFORMATION AND MATERIAL ARE NOT GIVEN. PLEASE RESUBMIT 2 SETS OFORIGINAL PLANS WITHIN 30 DAYS OF THE BELOW DATE.

Reviewer:_____________________________ (Tel/ 718 – 595 –5463 • Fax/ 718 – 595 –5252 Date:_________________

	Rev 6/10
Page 7	Rev. 06/10

Definitions for Commonly Used Cross-Connection Terms

AFF – Above finished floor.

Airgap – means the unobstructed vertical distance through the free atmosphere between the lowest opening from a pipe, RPZ discharge port, drain line or faucet supplying water to a tank, plumbing fixture floor drain, or any other device. This approved airgap shall be at least double the diameter of the supply pipe, measured vertically, above the overflow of the vessel; and in no case less than one inch. For RPZ’s, an airgap may be based on twice the effective diameter of the relief port.

Airgap Fitting – is a manufactured device which fits on the RPZ’s discharge port and is designed to serve as an airgap. When a manufacturer’s airgap fitting is used and a drain pipe carries the relief port discharge to a drain or sewer, an additional free atmosphere airgap is needed between the end of the relief port discharge pipe and the drain or sewer opening.

Acceptable Backflow Prevention Device – is an acceptable airgap, approved reduced pressure zone device (RPZ), or approved double check valve (DCV, DCVA). Approved devices are those that are listed by The New York State Department of Health.

Aesthetically Objectionable – refers to substances (e.g. stagnant water, hot water) which if introduced into the water supply system, could be a nuisance to other water customers but would not adversely affect human health.

Approved Device – RPZ or DCV, which has been listed by The New York State Department of Health as an acceptable backflow prevention device. Others are not acceptable.

Backflow – The reversal of the normal flow of water caused by either backpressure or backsiphonage.

Containment – the means which isolate customers’ entire facility from the public water system so as to provide the protection necessary to prevent contamination of the public water supply in the event of contamination within the customers’ facilities.

DCV – double check valve, device with two single, independently acting check valves, including tightly closing shutoff valves located at each end of the assembly and suitable connections for testing the watertightness of each check valve, and listed by the New York State Department of Health.

Hazardous Facility – is one in which substances may be present which if introduced into the public water system would or may endanger or have an adverse effect on the health of other water customers.

Horizontal Alignment - the distance from the middle of the device to the nearest front or back wall, and the distance to the nearest side wall. (In some cases, reference can be made to a column, curb, or some fixed conspicuous object.

MOCV – Meter Outlet Control Valve, the line valve that is used in conjunction with the test tee to test the meter. This valve shall be located on the house side of the test tee in order to prevent water flow to and from the facility during meter testing.

RPZ – Reduced Pressure Zone Backflow Prevention Device. A device containing two independently acting check valves on both sides of an automatically operated pressure differential relief valve, all located between two resilient seated shutoff valves. Acceptable devices must be listed by the New York State Department of Health.

Side Clearance – is the clear horizontal distance between the side of the device to the nearest side wall (i.e. wall parallel to the water flow).

Test Tee – a tee used for testing the meter.

Vertical Position – distance above the finished floor AND

the

Page 8

Rev. 06/10

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

New York City Department of Environmental Protection Form for Report on Test and Maintenance

Bureau of Water and Sewer Operations

of Backflow Prevention Device

Please use a separate form for each device

Initial Test

Complete entire form

Part A- TO BE COMPLETED IN ALL CASES

Annual Test – For the Year ____.

Complete Part A & B Only

Public Water Supply:

County:

Block:

Lot:

Department Use Only

Name & Address of Facility:

Manufacturer & Model of Device:

__________________________________________________

Size & Serial # of Device.

__________________________________________________

Location of Device:

Part B- TO BE COMPLETED BY CERTIFIED BACKFLOW PREVENTION DEVICE TESTER

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 Service (Please Circle One):

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

Domestic

Fire

Combined

Question 1: Are there any connections between the point of entry and the backflow prevention device, or other deficiencies?

CERTIFICATION: This device meets the requirements of an		CERTIFICATION: This device does NOT meet the requirements.
acceptable containment device at the time of testing. I
hereby certify the foregoing data to be correct.
___________________________________	____/____/____	___________________________________		____/____/____
Signature	Date		Signature	Date
Signature	Date
_________________________________	(____)______-_________		______________________________	____/____/____
PRINT NAME	Telephone No.		Certified Tester No.	Expiration Date

Part C- TO BE COMPLETED BY PROFESSIONAL OR REG. ARCHITECT

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.

Water Supplier 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 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 with original ink signatures and original ink or impressed seals to NYC Department of Environmental Protection, Division of Permitting & Inspections, Cross Connection Control Unit, 59-17 Junction Boulevard, 3rd Fl. Low-Rise, Flushing, NY 11373 within 30 days of installation and initial testing.

Page 9

Rev. 06/10

NYC GEN215B Revised (6/08)

INSTRUCTION FOR COMPLETION OF

“Report on Test and Maintenance of Backflow Prevention Device”

(FORM GEN-215B)

Use a separate form for each device

Initial Test and Certification: complete all 4 parts

Annual Re-Certification: complete parts A and B only

Part A: To be completed in ALL cases:

Part B: Certified Backflow Prevention Device Tester must fill out this portion in All cases:

•Be sure to answer Question 1. If the answer is “YES”, explain in the space provided. A connection for a properly installed and certified parallel device should not be construed as a connection. Hose cocks and spigots must be considered as connections. Tees must be considered as outlets unless they have been PERMANENTLY plugged or sealed. (Tees may be plugged by welding on blank flanges or by screwing in a plug and cutting the plug off flush with the face of the tee). Plugged tees will only be acceptable for old work. Tees on the street side of the backflow prevention device will not be allowed on new jobs. Risers, feeds to boilers and the like must be construed as connections.

•Indicate INITIAL TEST or Re-CERTIFICATION

•Clearly print, type or rubber stamp: Name, Certified Tester # and Certified Tester Expiration Date

•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).

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

•If there is no water meter, indicate this on the form.

Part C: Complete For INITIAL TEST Only!

•The Professional Engineer or Registered Architect (PE/RA) must complete Part C.

•Be sure to fill in the “Water Supplier Approval #”

•Indicate whether you are the designer of record or not

•Indicate minor changes if there are any. Use back or additional pages as required.

•Indicate “See Back” or “See Additional Pages” as appropriate. If a device different than the approved device is used, the PE or RA must specify that the submission is acceptable and will not cause any adverse hydraulic effects

•If the installation changes meet DEP requirements while deviating from the approved plans, the job may be resubmitted for re-approval or an As-built Record Drawing may be submitted

•When the installation deviates from the approved plans and required minimums are not satisfied, the job should NOT be certified.

Part D: The Professional Licensed Master Plumber must complete Part D

•Be sure to fill in the Building Department Number (ARA #, ALT#, NB#, etc). Use of sticker is preferred.

•Indicate if you are the Licensed Master Plumber of record or not

•Indicate Licensed Master Plumber’s Name. Licensed Master Plumber’s License #. Licensed Master Plumber’s Telephone Number. Use Original Ink Signature Raised Impression Seal of Licensed Master Plumber & Date

The Tester, the PE or RA & the Licensed Master Plumber should all sign the same form for each particular device.

For each of the completed forms, USE ORIGINAL INK SIGNATURES & ORIGINAL INK OR RAISED IMPRESSION SEALS.

Mail one completed Form to:

Department of Environmental Protection

Division of Permitting & Inspections

Cross Connection Control Unit

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

Page 10

Rev. 06/10

ACCEPTABLE DOUBLE CHECK VALVE (DCV) ASSEMBLIES

COMPANY

MODEL

SIZE (IN INCHES)

SERIES

0.50

0.75

1.00

1.25

1.50

2.00

2.50

3.00

4.00

6.00

8.00

10.00

2000SS

H+V↑

AMES

2000B

H+V↑

COLT200A

H+V↑

MAXIM200A

H+V↑

COLT200NA

H↑I↓O

MAXIM200NA

H↑I↓O

BUCKNER

24100

D-2

D-4

DC6LW

H+V↑

CLA-VAL

DC7L (W/Y)

H+V↑

DC8L (W/Y)

H+V↑

DC8N (W/Y)

N↑

DC8V (W/Y)

40-100

CONBRACO

4SG-100

H+V ↑

H+V↑

H+V ↑

4SG-100U

H↑I↓O

DC (AKA 4S-100)

H+V↑

40-106-A2

40-106-997

805 YD

H+V↑

FEBCO

850

H+V↑

870

H+V↑

870V

H+V↑

870 –N SHAPE

870V- Z SHAPE

DCVE

FLOMATIC

DCV

HERSEY/

NO. 2

FDC

GRINNEL

HDC

KENNEDY

1373

ORION

BDC

007

H+V↑

H↑I↓O

007MIQT

H↑

007M2QT

H+V↑

007M3QT

WATTS

709

H↑I↓O

H+V↑

719QT

719AQT

U719QT

774

H+V↑

757

H+V

757A

H+V↑

757NA

H↑I↓O

350

H+V↑

350A

H+V↑

350XL

H+V↑

950XL

H+V↑

WILKINS

950XL OS&Y

950XLT

950XLT2

950XLU

450

H↑I↓O

Page 11

Rev. 08/10

ACCEPTABLE REDUCED PRESSURE ZONE (RPZ) DEVICES

COMPANY

MODEL

SIZE (IN INCHES)

SERIES

0.25

0.375

0.50

0.75

1.00

1.25

1.50

2.00

2.50

3.00

4.00

6.00

8.00

10.00

4000SS

AMES

4000B

4000BM2

COLT400

MAXIM400

COLT400N

H↑I↓O

COLT400Z

H↑I↓O

MAXIM400N

H↑I↓O

MAXIM400Z

H↑I↓O

BUCKNER

24000

RP-2

RP-4

RP-4V

RP6LW

CLA-VAL

RP6VW

RP7L (W/Y)

RP8L (W/Y)

RP8N (W/Y)

RP8V (W/Y)

CONBRACO

40-200

40-200A2S

825 Y

825 YA

FEBCO

825 YD

860

880-N

880V-Z

RPZIIE

FLOMATIC

RPZE

RPZ

RPZII

HERSEY/

6CM

GRINNEL

FRP-2

ORION

BRP

U009

009

009QT

U009QT

909

909QT

H+V↑

WATTS

909M1QT

919QT

H+V↓

957

957N

H↑I↓O

957Z

H↑I↓O

U009M2AQT

009M2QT

009M3QT

994

375

375A

475

H↑I↓O

475V

H↑I↓O

WILKINS

975XL

975XL2

975XLV

H↑I↓O

975XLU

975XLMS

975XLBMS

975XLSE

H↑I↓↑O

975XLSEU

H↑I↓O

Page 12

Rev. 08/10

ACCEPTABLE DOUBLE CHECK DETECTOR (DCD) ASSEMBLIES

MODEL

SIZE (IN INCHES)

COMPANY

0.5

SERIES

0.75

1.00

1.25

1.50

2.00

2.50

3.00

4.00

6.00

8.00

10.00

C300

AMES

3000 SE

H+V↑**

3000 SS

H+V↑**

3000B

DD7LY

H+V↑*

CLA-VAL

DD8LY

H+V↑*

DD8NY- N

H+V↑

DD8VY – Z

CONBRACO

40-600

DCDA (AKA 4S-

H+V↑

600)

4SG-600

H+V↑

4SG-600U

↑↓V

806 YD

H+V↑**

H**

FEBCO

856

H+V↑**

876

H+V↑**

H**

876V

H+V↑**

HERSEY/

DDC-II

GRINNEL

H**

007 DCDA

H+V↑**

709 DCDA

H↑I↓O**

H+V↑*

757

H+V

WATTS

757A

H+V↑

774 DCDA

H+V↑

757A-DCDA-

H+V↑

BF/GV

350DA

H+V↑

WILKINS

350ADA

H+V↑

450DA

H↑I↓O

950XLTDA

H+V↑

950XLTDA BF

ACCEPTABLE REDUCED PRESSURE DETECTOR (RPD) ASSEMBLIES

COMPANY

MODEL

SIZE (IN INCHES)

SERIES

0.25

0.375

0.50

0.75

1.00

1.25

1.50

2.00

2.50

3.00

4.00

6.00

8.00

10.00

AMES

5000CIV

CLA-VAL

RD7LY

CONBRACO

40-700

FEBCO

826YD

H**

HERSEY/

6CM RPDA

GRINNEL

WATTS

909 RPDA

H**

375DA

375ADA

WILKINS

475DA

H↑I↓O

475DAV

H↑I↓O

NOTES:

- These devices are acceptable as Backflow Prevention Devices, check with the Bureau of Water & Energy Conservation for acceptability as

Detector Checks.

- These devices are acceptable as Detector Checks by the Bureau of Water & Energy Conservation as of June 7, 1994.

- Horizontal installation

↑

- Vertical installation (flow up)

(W/Y) – Non-rising stem and outside stem & yoke, respectively

↓

- Vertical installation (flow down)

N – “N” Configuration: refer to manufacturer’s literature

G -4”” x 4”” x 8”” Manifold”

↑i↓o

- Vertical up inlet and vertical down outlet

Z – “Z” Configuration: refer to manufacturer’s literature

GG -6”” x 6”” x 10”” Manifold”

SOURCES: New York Department of Health, Office of Public Health, Center for Environmental Health, Environmental

Health Manual, Technical Reference, Item No. PWS 14, Dated: 04/15/94 & Supplements 05/03/94, 11/22/94, & 7/17/95;

6/26/97; 10/15/98; 3/10/99; 7/21/99; 1/27/00; 5/10/00; NYC DEP Bureau of Water & Energy Conservation, Water Meter Approval List, Dated: 06/07/94.

Page 13

Rev. 08/10

Question	Answer
Form Name	Nyc Dep Backflow Form
Form Length	30 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min 30 sec
Other names	how to nyc backflow prevention, nys backflow, nyc dep backflow, nyc doh backflow prevention

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