ASSE Backflow Tester Certification and Gauge Calibration Log

Log for tracking ASSE backflow tester certification, test kit serial numbers, annual gauge calibration certificates, and jurisdictional registration details.

Tester Identification

• Tester Name
• ASSE 5110 Certification Number
  Enter the tester's ASSE 5110 certification number as shown on the credential.
• Certification Expiration Date

Test Kit and Gauge Information

• Test Kit Serial Number
• Test Kit Manufacturer
• Gauge Calibration Certificate Number
  Record the annual calibration certificate number for the gauge/test kit.
• Gauge Calibration Date
• Gauge Calibration Expiration Date

Jurisdictional Registration

• Jurisdiction / Authority Having Jurisdiction (AHJ)
• Jurisdictional Registration Number
• Registration Status
• Registration Expiration Date

Renewal and Audit Notes

• Last Verified Date
• Verification Notes
  Add any compliance notes, renewal reminders, or exceptions. Do not include unnecessary PII.
• Supporting Document
  Upload a copy of the certification card, calibration certificate, or registration document.