Backflow Preventer Field Test Report

Inspection template for documenting field testing of backflow prevention assemblies, including reduced pressure (RP), double check (DC), double check detector assembly (DCDA), pressure vacuum breaker (PVB), and spill-resistant vacuum breaker (SVB) devices, with calibrated gauge identification and corrective actions.

Inspection Identification

• Inspection date and time recorded
• Site name and service address entered
• Water purveyor or AHJ identified
• Test purpose documented

Device Identification

• Backflow assembly type selected
• Manufacturer and model recorded
• Assembly size recorded
• Assembly serial number recorded
• Installation location identified

Test Equipment and Calibration

• Test gauge serial number recorded
• Test gauge calibration date current
• Gauge calibration is within required interval
• Test kit hoses, fittings, and adapters free of visible damage or leakage
• Test equipment identified as suitable for the assembly tested

Field Test Readings

• Test method and sequence followed for the assembly type
• First check valve differential pressure reading
• Second check valve differential pressure reading
• Relief valve opening point or air inlet opening point recorded, as applicable
• Shutoff / hold performance verified
• No visible leakage, spitting, or abnormal discharge observed during test

Compliance, Deficiencies, and Sign-Off

• Assembly passed field test
• Deficiencies or non-conformances documented
• Corrective action and retest required
• Tester certification number recorded
• Inspector signature