Form Gen215b - Form For Report On Test And Maintenance Of Backflow Prevention Device
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1
2New 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
Annual Test – For the Year ____.
Complete Part A & B Only
Part A- TO BE COMPLETED IN ALL CASES
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
Differential Pressure
Check Valve No. 1
Check Valve No. 2
Line Pressure ____ psi
Relief Valve (RPZ only)
Pressure drop across first
check valve, psi ____
Leak
( )
Test Before Repair
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:
Type of Service (Please Circle One):
Completion Time of
Domestic
Fire
Combined
Test (e.g. 3:15 pm):
Question 1: Are there any connections between the point of entry and the backflow preventer, or
other deficiencies?
*If YES, please explain in detail in the space provided or on an additional paper.
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
_________________________________
(____)______-_________
______________________________
____/____/____
PRINT NAME
Telephone No.
Certified Tester No.
Expiration Date
Part C- TO BE COMPLETED BY PROFESSIONAL OR REG. ARCHITECT
Part D – TO BE COMPLETED BY MASTER PLUMBER
Professional Engineer’s or Registered Architect’s Certification:
Master Plumber’s Certification:
[ ] I am
[ ] I am NOT the Licensed Master
I have personally checked this installation and I certify that it is in accordance with the
Plumber of Record. I have personally checked this installation and I certify that it is in
approved plans.
accordance with the Building Department’s Requirements.
Water Supplier Approval #:
Building
Department
Number:
(Use Sticker)
[ ] I am the Designer of Record. [ ] I am NOT the Designer of Record.
PE/RA Printed Name:
___________________________________________
Company:
___________________________________________
Plumber’s Printed Name:
_______________________________________
Address:
___________________________________________
Plumber’s License #:
_______________________________________
Telephone #:
___________________________________________
Telephone #:
_______________________________________
Signature, Seal & Date:
Signature, Seal and Date:
Minor Installation Changes (describe):
Attach additional sheets if required.
NOTE:
Send one completed form with original ink signatures and original ink or impressed seals to NYC Department of Environmental Protection, Division of
rd
Permitting & Inspections, Cross Connection Control Unit, 59-17 Junction Boulevard, 3
Fl. Low-Rise, Flushing, NY 11373 within 30 days of installation
and initial testing.
NYC GEN215B Revised (6/08)
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