Backflow Preventer Test Report Form

Backflow Preventer Test Report Form
Use this form to record backflow preventer inspection and test results for a property or facility.
Site and Property Information
Facility/Site Name
Service Address
City
State/Province
Postal Code
Contact Person and Contact Info
Device Identification and Test Details
Device Type / Model
Manufacturer
Serial Number
Device Location on Site
Test Date
MonthDayYear
Date
Test Time
Hour Minutes
AM/PM Option
Reason for Test
Other
Water Service / Line Protected
Tester Information and Certification
Tester Name
First NameMiddle NameLast Name
Company / Business Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Certification / License Identifier
Certification Expiration Date
MonthDayYear
Date
Test Equipment and Calibration
Test Kit / Instrument ID
Calibration Due Date
MonthDayYear
Date
Calibration Status
Other
Test Readings and Results
Test Readings by Component
Rows Reading 1 Reading 2 Reading 3 Result
Check Valve 1
Check Valve 2
Relief Valve
Shutoff Valve A
Shutoff Valve B
Inlet Pressure (psi)
Intermediate Pressure (psi)
Outlet Pressure (psi)
Overall Test Result
Notes on Unusual or Incomplete Readings
Deficiencies, Repairs, and Recommendations
Deficiency Description
Repair Description
Observed Deficiencies
Other
Device Status After Inspection
Recommended Follow-Up Actions
Report Submission
Report Preparer Name
First NameMiddle NameLast Name
Submission Date
MonthDayYear
Date
Final Comments / Remarks
Accuracy Acknowledgment
Other
Should be Empty:

Select theme:

Rows	Reading 1	Reading 2	Reading 3	Result
Check Valve 1
Check Valve 2
Relief Valve
Shutoff Valve A
Shutoff Valve B

Backflow Preventer Test Report Form

Site and Property Information

Device Identification and Test Details

Tester Information and Certification

Test Equipment and Calibration

Test Readings and Results

Deficiencies, Repairs, and Recommendations

Report Submission