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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
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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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