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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.

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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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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.

Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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