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Backflow Inspection Form


With this form, 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. Here is the basic framework of this checklist template:

  • • General pipe information
  • • Assembly information
  • • Test and repair information
  • • Pressure release valve
  • • Pressure vacuum breaker
  • • Gauges
  • • Approvals

  • You can also check out our backflow preventer inspection checklist article.

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Backflow Inspection Form

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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