Backflow Preventer Annual Test

Annual inspection template for documenting backflow preventer test results, device type, readings, certification, and corrective actions.

Inspection Details

• Inspection date and time
• Facility name and location
• Inspector / certified tester name
• Tester certification number
• Certification expiration date
• Inspection purpose
• Reference standard or local authority requirement
  Record the applicable code, standard, or AHJ requirement used for the inspection.

Backflow Device Identification

• Device type
• Manufacturer
• Model number
• Serial number
• Size
  Record nominal pipe size, such as 1 in, 2 in, or 4 in.
• Installation location
  Identify the exact physical location of the device, including building, room, vault, or riser.

Test Readings and Functional Results

• Initial condition of device and test ports
• Upstream pressure
• Downstream pressure
• Relief valve opening pressure
• Check valve 1 differential pressure
• Check valve 2 differential pressure

Certification and Compliance

• Test result
• Certification statement completed
  Confirm the tester has signed or otherwise certified the results as accurate.
• AHJ or customer notified of failure
• Inspection report number

Deficiencies and Corrective Actions

• Deficiencies observed
• Corrective action required
• Corrective action details
  Describe repairs, replacement, retest requirements, or follow-up actions needed.
• Retest required