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Backflow Test Report

Backflow Test Report

Use this inspection form to prevent backflow. Plumbers can more quickly identify the source of the problem.

Use this template
or download pdf
Backflow Test Report

Use this inspection form to prevent backflow. Plumbers can more quickly identify the source of the problem.

Use this template
or download pdf

About the Backflow Test Report

With this backflow test report, plumbers can document backflow inspection test results and schedule repairs. Determine the cause of the problem by going step-by-step through this list. Inspect the pipe for leaks or determine if the valve is too tight. Check out the CV assembly, disc, o-ring, seat, springs, stem, retainer, and nuts.

Understanding the Importance of a Backflow Test Report

A backflow test report is a document that provides information on the status of a backflow prevention device. This device is essential for protecting the quality of drinking water by preventing the contamination of the main water supply with pollutants or other harmful substances.

The report typically includes details on the testing process, including the location and type of backflow prevention device, as well as the results of the test. It may also include recommendations for repairs or maintenance needed to ensure the device is functioning properly.

In many areas, including commercial and industrial properties, regular backflow testing is required by law. This helps ensure that the devices are working properly and that the water supply is safe.

Using a backflow test report can provide peace of mind to property owners and help maintain compliance with regulatory requirements. It also promotes the long-term health and safety of the water supply by preventing contamination from harmful substances.

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  • Maintenance templates
Preview of the template
Audit
I. General Information
Name:
Mailing Address:
Phone:
Fax:
Location of Assembly Address:
Type of Building:
A. Assembly Information:
Type of Assembly:
Date of installation:
Incoming line pressure:
Manufacturer:
Model No.:
Serial No.:
Size:
Location of Assembly:
Assembly Type:
II. Tests and Repairs Information
Gauge:
Make:
Serial No.:
Date Calibrated:
Type of Installation:
Old Assembly Serial No.:
A. Check Valve #1
Initial Test:
Leaked
Closed Tight?
Pressure Drop Across the First Check Valve (PSI)
List of repairs and corrections Check Valve #1:
Cleaned only
Rubber Kit
CV Assembly
Disc
O-ring
Seat
Spring
Stem/Guide
Retainer
Lock Nuts
Other
Gauge Pressure Across Check Valve (PSI)
Final Test:
Closed tight?
B. Check Valve #2
Initial Test:
Leaked
Closed Tight?
Pressure drop across the second check valve (PSID).
List of repairs and corrections Check Valve #2:
Cleaned only
Rubber Kit
CV Assembly
Disc
O-ring
Seat
Spring
Stem/Guide
Retainer
Lock Nuts
Other
Gauge Pressure Across Check Valve (PSI)
Final Test:
Closed tight?
C. Differential Pressure Relief Valve
Initial Test:
Did it open?
If "Yes" list the PSID:
List of repairs and corrections to Differential pressure relief valve:
Cleaned only
Rubber Kit
CV Assembly
Disc
O-ring
Seat
Spring
Stem/Guide
Retainer
Lock Nuts
Other
Final Test:
Opened at (PSID):
D. Pressure Vacuum Breaker
Initial Test:
Did the Air Inlet open?
If "Yes" list the PSID:
List of repairs and corrections to Differential pressure relief valve:
Cleaned only
Rubber Kit
CV Assembly
Disc
O-ring
Seat
Spring
Stem/Guide
Retainer
Lock Nuts
Other
Final Test:
Air Inlet (PSID):
Check Valve (PSID):
Condition of no. 2 control valve:
NOTE: All repairs shall be completed within five (5) working days.
Time:
Buffer PSID:
Remarks:
III. Approvals
I HEREBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE ASSEMBLY.
Print Name of Tester
Tester's Signature
Testers Phone#
Cert. No.
Date of Inspection:
This Assembly:
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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Template collections

See comprehensive collections of best practice templates related to this topic.

Leak Inspection ChecklistThe Precision-made Backflow Preventer Inspection Checklist You Need
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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