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Backflow Test

Follow this procedure for proper documentation of the successful backflow test.
Backflow Test
07/06/2023

Backflow Test

Follow this procedure for proper documentation of the successful backflow test.

    PROPERTY STATUS

    PROPERTY NAME

    MAILING ADDRESS

    CITY

    STATE

    ZIP

    PHONE

    PREVENTER ADDRESS

    WATER SUPPLIER

    DEVICE LOCATION

    TYPE

    MAKE

    SERIAL #

    MODEL

    SIZE

    HAZARD PROTECTED

    INITIAL TEST RESULTS-REDUCED PRESSURE ASSEMBY

    REDUCED PRESSURE ASSEMBLY CHECK #1

    Press Drop: (MIN 5 PSID)

    RELIEF VALVE

    Opened at: (MIN 2 PSID)

    RELIEF VALVE

    PASS/FAIL

    • Pass
    • Flag
    • Fail

    REDUCED PRESSURE ASSEMBLY DOUBLE CHECK # 1

    MIN 1 PSID

    REDUCED PRESSURE ASSEMBLY DOUBLE CHECK # 1

    REDUCED PRESSURE ASSEMBLY DOUBLE CHECK # 2

    MIN 1 PSID

    REDUCED PRESSURE ASSEMBLY DOUBLE CHECK # 2

    PVBA/SVBA - AIR INLET

    Opened at : (MIN 1 PSID)

    PVBA/SVBA - AIR INLET

    Result

    PVBA/SVBA - CHECK VALVE

    Press Drop : (MIN 1 PSID)

    PVBA/SVBA - CHECK VALVE

    PASS/FAIL

    • Pass
    • Flag
    • Fail

    INITIAL TEST RESULT

    • Pass
    • Flag
    • Fail

    DATE

    SYSTEM PSI

    DETECTOR METER READING

    NOTES REPAIRS PARTS

    COMMENT

    TEST AFTER REPAIRS-REDUCED PRESSURE ASSEMBY

    REDUCED PRESSURE ASSEMBLY CHECK #1

    Press Drop: (MIN 5 PSID)

    RELIEF VALVE

    Opened at: (MIN 2 PSID)

    RELIEF VALVE

    PASS/FAIL

    • Pass
    • Flag
    • Fail

    D.C.V.A. CHECK # 1

    MIN 1 PSID

    D.C.V.A. CHECK # 1

    D.C.V.A. CHECK # 2

    MIN 1 PSID

    D.C.V.A. CHECK # 2

    PVBA/SVBA - AIR INLET

    Opened at : (MIN 1 PSID)

    PVBA/SVBA - AIR INLET

    Result

    PVBA/SVBA - CHECK VALVE

    Press Drop : (MIN 1 PSID)

    PVBA/SVBA - CHECK VALVE

    PASS/FAIL

    • Pass
    • Flag
    • Fail

    TEST RESULT AFTER REPAIRS

    • Pass
    • Flag
    • Fail

    DATE

    GUAGE S/N

    MAKE/MODEL

    CALIBRATION DATE

    INITIAL TESTER

    TESTER SIGNATURE

    Click here to sign

    TESTER NAME

    TESTER ADDRESS

    COMPANY NAME

    TESTER AFTER REPAIRS

    TESTER SIGNATURE

    Click here to sign

    TESTER NAME

    TESTER ADDRESS

    COMPANY NAME

    TESTER CERT #

    PHONE

    WATER RESTORED

Source: Backflow Test (Community Member)

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