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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 preventer 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 by checking the appropriate choice.

Then 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 #:”

Check 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:

To be completed by the Licensed Master Plumber. Be sure to fill in the following:

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

Check whether you are the Licensed Master Plumber of record or not.

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 and Date

The tester, the PE or RA and 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 & Connections

Cross Connection Control Unit

59-17 Junction Boulevard, 3

Fl. Low-Rise

Corona, NY 11368

Form Gen215b - Form For Report On Test And Maintenance Of Backflow Prevention Device Page 2

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