Lumiform / Templates / Backflow Inspection Form

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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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.