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Run: Backflow Preventer Field Test Report

Field-test backflow preventer assemblies and record the readings, device details, calibration status, and pass/fail outcome in one report. Use it to document...

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Inspection Identification

Inspection date and time recorded critical (required)

Site name and service address entered critical (required)

Water purveyor or AHJ identified critical (required)

Test purpose documented

Device Identification

Backflow assembly type selected critical (required)

Manufacturer and model recorded critical (required)

Assembly size recorded critical (required)

Assembly serial number recorded critical (required)

Installation location identified critical (required)

Test Equipment and Calibration

Test gauge serial number recorded critical (required)

Test gauge calibration date current critical (required)

Gauge calibration is within required interval critical (required)

Yes No N/A

Test kit hoses, fittings, and adapters free of visible damage or leakage critical (required)

Yes No N/A

Test equipment identified as suitable for the assembly tested critical (required)

Yes No N/A

Field Test Readings

Test method and sequence followed for the assembly type

First check valve differential pressure reading critical (required)

Second check valve differential pressure reading critical (required)

Relief valve opening point or air inlet opening point recorded, as applicable critical (required)

Shutoff / hold performance verified critical (required)

Yes No N/A

No visible leakage, spitting, or abnormal discharge observed during test critical (required)

Yes No N/A

Compliance, Deficiencies, and Sign-Off

Assembly passed field test critical (required)

Yes No N/A

Deficiencies or non-conformances documented

Note (optional)

Corrective action and retest required

Yes No N/A

Tester certification number recorded critical (required)

Inspector signature critical (required)

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