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Free Nyc Dep Backflow Form in PDF

The NYC DEP Backflow Prevention Form serves as a critical regulatory tool aimed at safeguarding New York City's water supply from contamination risks. Drafted by the Department of Environmental Protection, this comprehensive document guides property owners on the proper installation, testing, and maintenance of backflow prevention devices. These steps are essential for ensuring that potentially contaminated water does not reverse flow into the city's clean water supply, thus upholding public health and safety.

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Ensuring the safety and purity of New York City’s water supply is a critical concern for the Department of Environmental Protection (DEP). With the introduction of the revised supplemental guide to the New York State Department of Health Handbook for Cross Connection Control, property owners now have a detailed roadmap for the installation and maintenance of backflow prevention devices. This resource is indispensable for those who own or manage premises identified as having actual or potential risks of contaminating the city's water supply—ranging from auto repair shops to medical laboratories. The supplement clearly outlines the necessity for these devices, the legal requirements for their installation, and the annual inspection protocol to ensure they function correctly. It is meticulously designed to avert the unintended consequence of contaminated water reversing back into the public supply. Furthermore, it places significant responsibility on professional engineers, registered architects, and licensed plumakers to ensure that plans are not only thoroughly developed but also approved by the DEP before any installation begins. The ultimate goal is to protect public health while minimizing the risk of pollution to New York City's water system, emphasizing the need for compliance every step of the way.

Nyc Dep Backflow Sample

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 Dep Backflow

File Overview

Fact	Detail
Who is affected	Owners of properties that pose an actual or potential risk of contamination to New York City’s water supply. This includes properties with facilities like bakeries, auto body shops, dental offices, and medical laboratories.
Governing Laws	The DEP’s Bureau of Water and Sewer Operations enforces 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).
Compliance Steps	Property owners must have backflow prevention devices installed by a licensed plumber, tested annually by a state-certified tester, and have the installation approved by the DEP.
Submission and Approval Process	Professional Engineers (PE) or Registered Architects (RA) must submit plans and applications for backflow prevention devices. These must be approved by the DEP before installation can proceed.

Nyc Dep Backflow: Usage Guidelines

Filing for a Backflow Prevention Device installation in New York City involves a detailed process that ensures the safety of the city's water supply. The primary purpose here is to prevent any form of contamination that might reverse flow back into the public water system. With that goal in surveillance, a series of steps are outlined for property owners, emphasizing the need for professional involvement in both the preparation of the submission and the physical installation and maintenance of the device. By following these steps meticulously, property owners fulfill their legal obligations and contribute to the broader public health initiative of keeping NYC's water safe and clean.

Engage a Professional Engineer (PE) or Registered Architect (RA) to prepare two sets of plans alongside two original application forms (form GEN-236). These documents must bear original signatures and seals in ink.
Submit the prepared plans and applications for the Backflow Prevention Device installation to the NYC Department of Environmental Protection’s (DEP) Bureau of Water and Sewer Operations, Division of Permitting and Inspections. Ensure any corrections pointed out are duly made and re-submitted until the plans are accepted.
Upon approval, a plan approval letter is issued. At this point, a New York City Licensed Master Plumber should perform the installation as per the approved plans. Note that the installation has to comply with additional requirements set by the Building Department and the Bureau of Customer Service.
The installed device must then be tested by a State certified Backflow Prevention Device Tester, who could be a Licensed Master Plumb or an individual employed by one. Thereafter, an inspection by the initial PE or RA is required to certify that the installation aligns with the approved plans.
Complete and submit the “Report on Test and Maintenance of Backflow Prevention Device” (Form GEN-215B) to DEP within thirty days following the installation. Any installations found to be improper will necessitate correction, re-testing, and re-certification until they meet the necessary standards.
Ensure the device undergoes an annual inspection, maintenance, and testing process by a state certified tester. The subsequent results and certifications should then be reported to DEP using Form GEN 215B with both parts A & B duly filled.

The manifesto provided outlines the requisite steps with an underpinning that emphasizes adherence to legal and professional standards. These processes aren't just bureaucratic hoops but are critically foundational in protecting public health through ensuring the integrity of the water supply system. Additionally, while some plumbers might offer an all-encompassing service covering installation to filing, the onus remains on the property owner to ensure that all standards are met and proper documentation is filed to avoid penalties and ensure compliance.

FAQ

What is the purpose of the DEP Backflow Prevention Supplement?

The DEP Backflow Prevention Supplement serves as a guide to assist in preparing backflow prevention plans for submission. It aims to ensure that backflow prevention device installations are planned and designed correctly, to protect New York City’s water supply from contamination. While it is a valuable resource, it is not a replacement for the expertise of a professional in the field of backflow prevention.
Who needs to comply with the requirements?

Property owners posing an actual or potential risk of contaminating the NYC water supply are required to comply. This includes, but is not limited to, owners of properties with facilities such as bakeries, auto repair shops, chemical processing plants, commercial kitchens, medical offices, and more. Essentially, any property that uses water in a way that could lead to contamination must ensure backflow prevention measures are in place.
What are the steps for compliance?

Compliance involves several steps:
- A Professional Engineer (PE) or Registered Architect (RA) must submit plans for the device(s).
- Approval of the plans by the Division of Permitting and Inspections.
- Installation of the device(s) by a licensed plumber, followed by testing and inspection.
- Submission of a “Report on Test and Maintenance of Backflow Prevention Device” within 30 days of installation.
- Annual inspection and testing of the device, with results reported to the DEP.
Can exemptions be requested?

Yes, exemptions can be requested. If a property owner believes their premise does not require a backflow prevention device, they can have a Professional Engineer, Registered Architect, or Licensed Master Plumber submit an exemption request to the DEP Cross Connection Control Unit for consideration. If approved, an exemption letter will be issued.
What are the requirements for plan submissions?

Plan submissions must include two sets of plans and two original GEN 236 application forms, bearing the original signature and seal of the applicant. The plans must detail all services being protected and list the NYS – DOH approved Backflow Prevention (BFP) Device(s). Certain installation requirements must also be met, such as no strainers are allowed before the meter and the device must be positioned between the meter and meter test tee.
How is the installation of Backflow Prevention Devices regulated?

Installation must be done according to the approved plans by a New York City Licensed Master Plumber. The installation includes specific requirements regarding the positioning of the device relative to the meter, the type of drainage solution needed, and clearances for maintenance and testing. Post-installation, the device must be tested by a certified backflow prevention device tester and inspected by a PE or RA to confirm compliance with the approved plans.
What happens if the installed device does not comply?

Non-compliant installations will be reported to the owner and the responsible PE or RA. Corrections must be made and the installation re-certified and submitted with a new Form GEN 215B. The DEP may inspect and verify all installations to ensure compliance.
Are there specific criteria for the displacement of devices and necessary clearance?

Yes, there are specific installation criteria including minimum clearances from walls, ceilings, and the floor, as well as air gap requirements for Reduced Pressure Zone (RPZ) devices' relief port to the drain based on the device size. Plans must also show accessible maintenance and testing provisions if the device is installed above a certain height or in a basement or cellar.

Common mistakes

Filling out the NYC DEP Backflow Prevention form requires careful attention to detail. However, several common mistakes can lead to delays or the need for resubmission. Here, we explore six errors often encountered during this crucial process.

The first mistake involves the lack of original signatures and seals. The form requires original ink signatures and ink or impression seals from a Professional Engineer (PE) or Registered Architect (RA). Photocopies or digital signatures are not accepted, yet some applicants overlook this requirement, leading to immediate rejection.

Lack of original signatures and seals: Failing to use original ink signatures and ink or impression seals leads to immediate rejection of the submission.
Not protecting all services of the facility: Every water service connection within the facility must be accounted for and protected. Overlooking even one can compromise the safety of the water supply.
Using non-approved backflow prevention devices: Only devices approved by the New York State Department of Health are acceptable. Using an unapproved device disregards compliance and safety standards.
Incorrect placement of strainers and take-offs: Strainers must not be placed between the water meter and the device, and no take-offs are allowed on the street side of the device except for approved combined services.
Improper installation location and clearance: The device must be installed with specific clearances from walls, obstructions, and in relation to the meter. Incorrect installation can lead to functional and regulatory compliance issues.
Failing to include required drawings and calculations: The submission must include an Elevation Plan, Floor Plan, Plot Plan, Engineering Report, and notes. Omitting any of these components can delay the approval process.

Aside from these mistakes, applicants must ensure that all relevant information is correctly filled out and that they closely follow the guidelines provided by the NYC DEP. For example, ensuring that drainage details for Reduced Pressure Zone (RPZ) backflow preventers are adequately shown and that elevation and clearance parameters are met according to the requirements. Additionally, providing accurate plot plans showing the entire facility's water service lines and ensuring the device is installed at the correct height and location are crucial for approval.

To avoid these common pitfalls, closely review all the requirements laid out in the DEP's guide and consider consulting with a professional experienced in the planning and design of backflow prevention device installations. This not only facilitates compliance but also ensures the safety of New York City's drinking water supply.

Furthermore, it's essential to remember the broader purpose of these regulations—to protect the public and the environment from potential contamination. By carefully following the DEP's guidelines and avoiding these six mistakes, property owners and professionals contribute significantly to maintaining the integrity and safety of the city's water system.

Documents used along the form

When dealing with the NYC DEP Backflow Prevention Program, a comprehensive approach is required to ensure the protection of New York City's water supply from contamination. Beyond the primary NYC DEP Backflow form, several other documents and forms play critical roles in ensuring compliance and safeguarding the city’s water. Each document is designed to fit into the overarching goal of maintaining a clean and uncontaminated water supply by preventing backflow incidents.

GEN-236 New York City Version: This form accompanies the DEP Backflow form for the submission of backflow prevention device installation plans to the Department of Environmental Protection. It must be filled out by a Professional Engineer (PE) or Registered Architect (RA) and includes detailed specifications of the proposed device installation.
Report on Test and Maintenance of Backflow Prevention Device (Form GEN-215B): This is a crucial document that is submitted annually or after the initial installation of a backflow prevention device. It certifies that the device has been properly tested and maintained, ensuring its optimal operation.
Request for Exemption: In situations where a property owner or their representative (PE, RA, or Licensed Master Plumber) believes that a backflow prevention device is unnecessary, they may submit a request for an exemption to the DEP Cross Connection Control Unit for evaluation.
Plan Approval Letter: This document is issued by the Division of Permitting and Inspections once the backflow prevention device installation plans have been reviewed and approved. It serves as official authorization to proceed with the installation as per the approved plans.
Building Department Permit: Many backflow prevention device installations require coordination with the city’s Building Department to ensure compliance with local building codes. A permit from this department may be necessary before beginning any plumbing modifications or installations.
Professional Certification of Installation: After the backflow prevention device is installed, it must be inspected by the PE or RA who submitted the initial plans. They must certify that the installation conforms to the approved plans. This document is essential for demonstrating compliance with DEP requirements.

These documents, when used in conjunction with the NYC DEP Backflow form, create a comprehensive framework for preventing backflow incidents and protecting the city’s water supply. Completing and submitting the appropriate forms at each required stage ensures that property owners remain in compliance with municipal water safety regulations. Understanding each document’s purpose and requirements is essential for navigating the process smoothly and effectively.

Similar forms

The NYC DEP Backflow Prevention Device Installation Proposal is similar to a Building Permit Application. Both documents require detailed plans, specifications, and approvals prior to any construction or installation. The Building Permit Application ensures that construction complies with local building codes and zoning regulations, while the Backflow Prevention form ensures water safety and compliance with health standards. Each document necessitates review and approval by relevant city agencies to proceed with intended projects, emphasizing adherence to safety and regulatory standards.

Another document akin to the NYC DEP Backflow form is the Environmental Resource Permit (ERP). Both documents focus on protecting environmental resources and public health through compliance with specific regulations. The ERP typically addresses activities impacting water bodies or wetlands, ensuring they do not harm the environment. Meanwhile, the Backflow form focuses on preventing contamination of public water supplies. Both require detailed submissions including plans, assessments, and sometimes mitigation strategies to gain approval.

The Occupational Safety and Health Administration (OSHA) Safety Plan shares similarities with the NYC DEP Backflow form regarding its emphasis on preventing harm. While the OSHA Safety Plan is broader, focusing on workplace safety and health protection, the Backflow Prevention form specifically targets water supply contamination risks. Each document requires the identification and mitigation of specific hazards, with a goal of ensuring safe environments—whether it be at the workplace in general or within a city’s public water system.

The Hazardous Materials Business Plan (HMBP) parallels the NYC DEP Backflow form in terms of its purpose to prevent environmental contamination. The HMBP requires businesses handling hazardous materials to disclose storage, use, and handling practices. Similarly, the Backflow Prevention form mandates disclosures related to water supply connections that might pose contamination risks. Both documents serve as preventative measures, ensuring that authorities are informed and appropriate safety devices or protocols are in place.

The Utility Connection Permit, required for establishing service connections like water, sewage, or electricity, also resembles the NYC DEP backflow form. Each document involves submitting detailed site plans and specifications, ensuring the proposed connections meet local and state codes for safety and functionality. Just as the Utility Connection Permit might address infrastructure impacts and compatibility, the Backflow form ensures that water connections will not compromise the municipal water supply.

Lastly, the Fire Safety Plan and the NYC DEP Backflow form share a common goal of protecting public health and safety through regulatory compliance. The Fire Safety Plan outlines measures to prevent or manage fires within buildings, requiring detailed building layouts and safety equipment specifications. Similarly, the Backflow form is concerned with preventing a different type of hazard—water supply contamination—requiring detailed plans for backflow prevention devices. Both are critical in their respective fields for the safeguarding of people and property.

Dos and Don'ts

When preparing to fill out the NYC Department of Environmental Protection (DEP) Backflow Prevention Device Installation Form, certain actions can facilitate the process, while others can create unnecessary complications. To navigate this process efficiently, consider the following guidance:

Do:

Consult with a Professional: If you're not experienced in planning and designing backflow prevention device installations, it is advisable to consult with a professional engineer or registered architect. Their expertise can ensure compliance and avoid errors.
Ensure Your Plans are Approved Before Installation: To avoid the expenses and delays associated with the removal and reinstallation of containment devices, have your plans approved by the DEP before proceeding. This proactive approach can save time and resources.
Submit Plans with Original Signatures: When submitting your plans and applications, ensure they bear the original ink signatures and seals of the responsible professional engineer or registered architect. This requirement is crucial for the validation of your submission.
Keep Up with Annual Inspections: Ensure that the backflow prevention device is tested by a state-certified tester at least once a year, and report the test results to the DEP by filing Form GEN 215B with parts A & B properly completed. Regular inspections are essential for maintaining compliance.

Don't:

Ignore Aesthetic Considerations: While aesthetic considerations and architectural design cannot be used as reasons for exemptions from installing containment devices, it's important to integrate them into your planning. The design must accommodate the containment devices, not vice versa. However, this integration should never compromise the installation's compliance or effectiveness.
Install Without DEP Approval: Proceeding with the installation of a backflow prevention device without the prior approval of the DEP can lead to significant complications. Such actions may result in the need for costly alterations or removals if the installation is found non-compliant.
Submit Incomplete or Incorrect Documents: Submitting plans and applications that are incomplete or contain errors can significantly delay the approval process. Make sure all submissions are thorough, accurate, and comply with DEP requirements to facilitate a smoother process.
Overlook the Importance of Proper Installation: Installing the device without adhering to the approved plans or bypassing the requirement for installation by a licensed master plumber can lead to improper installations. Such mistakes are not only violations but can also put the water supply at risk.

Misconceptions

When navigating the complexities of New York City's requirements for backflow prevention, it's easy to encounter misunderstandings. Here are four common misconceptions about the NYC DEP Backflow Prevention Program form and what you really need to know:

Only certain types of businesses need to comply. It's a common thought that only industrial or chemical processing facilities need to worry about backflow prevention. However, the program covers a broad range of properties, including bakeries, car washes, veterinary offices, and more. Essentially, any property that poses a potential risk of contamination to the city’s water supply is required to have a backflow prevention device installed and maintained.
The process is overly complicated and requires multiple forms. While the steps to comply with backflow prevention requirements are detailed, they are straightforward. Initially, it might seem overwhelming with mentions of plans, applications, and professional consultations. However, the process is broken down into manageable steps: submitting plans for approval, installation by a licensed plumber, testing by a certified tester, and annual inspections. One common form, the GEN-236, starts the process, emphasizing the need for professional oversight.
Approval before installation is optional. Some might assume that getting plans approved by the Department of Environmental Protection (DEP) before proceeding with the installation of a backflow prevention device is a recommendation rather than a requirement. This misunderstanding could lead to significant costs. Installing a backflow device without prior approval can result in the need for costly adjustments or even complete reinstallation if the setup doesn’t meet the DEP’s standards.
Any plumber can install the device. While many plumbers are capable of installing a variety of fixtures and devices, when it comes to backflow prevention devices in NYC, the installer must be a New York City Licensed Master Plumber. Additionally, the device must be tested by a state-certified backflow-prevention device tester, who may also be a licensed master plumber, ensuring that the installation complies with both city and state regulations.

Understanding these points can demystify the process and requirements of the NYC DEP Backflow Prevention Program, making compliance clearer and more straightforward for property owners across the city.

Key takeaways

Filling out and using the NYC DEP Backflow Prevention form is a critical process for property owners to ensure the safety of New York City’s water supply. Here are seven key takeaways to help understand and navigate the procedure:

Property owners must install backflow prevention devices if their properties pose an actual or potential risk of contaminating the city’s water supply. This includes, but is not limited to, premises such as bakeries, auto repair shops, beauty salons, and medical offices.
Before installing a backflow prevention device, plans must first be approved by the Department of Environmental Protection (DEP). A Professional Engineer or Registered Architect must submit these plans, emphasizing the importance of having professional insight during the planning phase.
The submission process requires two sets of plans and two application forms with original signatures and seals. It’s essential to adhere to these specific submission requirements to avoid delays in the approval process.
Once plans are approved, the device must be installed by a New York City Licensed Master Plumber according to the approved plans. This ensures that the installation meets DEP standards as well as other relevant building and customer service requirements.
The installed device must be tested by a State Certified Backflow Prevention Device Tester. This certification is crucial for verifying that the device functions correctly and complies with state regulations.
A “Report on Test and Maintenance of Backflow Prevention Device” form (GEN-215B) must be submitted to the DEP within thirty days of installation. This report is a critical step for documenting the device’s compliance and operational status.
An annual inspection and testing of the device must be performed by a state-certified tester, and the results reported to the DEP. Regular maintenance and testing ensure the long-term effectiveness of the device in protecting the water supply.

Understanding and following these guidelines will help property owners comply with regulations, protect public health, and ensure a safe water supply for New York City. Remember, the complexity of the process underscores the importance of consulting with professionals who are experienced in backflow prevention.

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