THE CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Rev 04/2022
Bureau of Environmental Compliance
59-17 Junction Boulevard, 9
th
Floor, Flushing, New York 11373
Records Control (718) 595–3855
Compliance Certification Form
Not on DEP Accepted List:
Bare Boiler
Burner
Assembly
Control Equipment
Premise Information
Address
Borough
Zip Code
Boiler Information
Manufacturer
Type
DEP Accepted List
Yes No
Max. Gross Output
(MMBTU/hr)
Heat Surface (ft
2
)
ASME Certified
Yes No
Combustion Chamber Dim.
(Inches)
Burner Information
Manufacturer
Type
DEP Accepted List
Yes No
Max Gross Input (
MMBTU/hr)
Fire rate
UL Listed
GPH
CFH
Yes No
Method of Burner Limitation
Boiler combustion chamber meets the minimum burner manufacturer’s requirement.
Yes No
Assembly Information
UL Listed Assembly?
Yes No
Control Equipment Information
Control
Model
Certification
Modulating Motor
UL ASME(CSD-1) CSA
Motorized Draft Regulator
UL ASME(CSD-1) CSA
Lead-Lag System
UL ASME(CSD-1) CSA
Fire Rate Control
UL ASME(CSD-1) CSA
Smoke Alarm
UL ASME(CSD-1) CSA
* If the control was certified by a different organization, elaborate in the General Information section
UL: Underwriters Laboratories
ASME(CSD-1): American Society of Mechanical Engineers (Controls and Safety Devices for Automatically Fired Boilers)
CSA: Canadian Standards Association
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THE CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Rev 04/2022
Bureau of Environmental Compliance
59-17 Junction Boulevard, 9
th
Floor, Flushing, New York 11373
Records Control (718) 595–3855
General information
Equipment nomenclature explanation ( Boiler, Burner and Controls)
Type of performance testing conducted (UL, HI, NRTL, etc.) please specify
Supplementary explanation if needed
Manufacturer datasheets must be attached with all non-accepted equipment
Professional Engineer Certification
I attest under the penalties of perjury:
1. I have personally examined and am familiar with the information contained in this submittal, including any and
all documents accompanying this certification statement.
2. That, based on my inquiry of those individuals responsible for obtaining the information, the information
contained in this submittal is, to the best of my knowledge, true, accurate and complete.
3. That, a licensed stationary engineer will be in attendance at the facility at all times.
4. I have personally reviewed the manufacturer’s test data and certify that the equipment will meet the following
operating conditions in the field:
a. A smoke reading of #3 or less on the Bacharach Scale
b. Stack losses will not exceed 17% for oil and 20% for natural gas
c. Overall efficiency will be at least 78%
5. That, at the time of owner equipment acceptance, overall efficiency tests according to the methods and
procedures outlined by ASME will be conducted and properly certified by a professional engineer registered in
the State of New York.
6. That, written notification will be made to the Department at least 15 days prior to any such tests so that
representatives of the Department may witness said tests.
7. That, combustion controls for the installation will be fully automatic with the air/fuel ratio being controlled by
feedback based upon continuous analysis of the flue gases at the boiler outlet and that this analysis will enable
the combustion controller to continuously maintain the operating conditions for overall efficiency, stack loss
and smoke readings as indicated above.
THE CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Rev 04/2022
Bureau of Environmental Compliance
59-17 Junction Boulevard, 9
th
Floor, Flushing, New York 11373
Records Control (718) 595–3855
8. That, the installation will have a means for continuously measuring the flue gas temperature at the boiler
outlet, a means of checking the smoke reading periodically and that measuring devices for such readings will be
easily accessible.
9. That, all other requirements of the Engineering Criteria for Fuel Burning Equipment (e.g. burner limitation,
turndown ratio, fractional firing rate indicator, pre and post purge, and engineering design data relating to
minimum setting, combustion chamber dimensions and maximum allowable furnace pressure) will be complied
with.
10. That systems to maintain compliance are in place at the facility and will be maintained even if processes or
operating procedures are changed.
11. I am fully authorized to make this attestation on behalf of the facility.
I am aware that there are significant penalties, including, but not limited to, possible fines and imprisonment, for
willfully submitting false, inaccurate, misleading or incomplete information.
PE Seal
Signature
Date
Name
Email