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Run: Backflow Preventer Annual Test

Annual backflow preventer test template for recording device identification, pressure readings, certification, and corrective actions in one inspection record.

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Inspection Details

Inspection date and time critical (required)

Facility name and location critical (required)

Inspector / certified tester name critical (required)

Tester certification number critical (required)

Certification expiration date critical (required)

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 critical (required)

Manufacturer critical (required)

Model number critical (required)

Serial number critical (required)

Size critical (required)

Record nominal pipe size, such as 1 in, 2 in, or 4 in.

Installation location critical (required)

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 critical (required)

Upstream pressure critical (required)

Downstream pressure critical (required)

Relief valve opening pressure

Check valve 1 differential pressure critical (required)

Check valve 2 differential pressure

Certification and Compliance

Test result critical (required)

Certification statement completed critical (required)

Confirm the tester has signed or otherwise certified the results as accurate.

Yes No N/A

AHJ or customer notified of failure

Yes No N/A

Inspection report number

Deficiencies and Corrective Actions

Deficiencies observed

Corrective action required critical (required)

Yes No N/A

Corrective action details

Describe repairs, replacement, retest requirements, or follow-up actions needed.

Retest required

Yes No N/A

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