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The purpose of this report is to verify that all backflow prevention assemblies are functioning correctly to protect the potable water supply from potential contamination or pollution due to backflow conditions. Testing must be conducted in accordance with current regulatory standards and manufacturer specifications by a certified backflow prevention tester.

Type of Device

RPZ (Reduced Pressure Zone)

PVB (Pressure Vacuum Breaker)

Permit Number

Client Information

Phone Number

Address

City

State

Zip Code

Device Information

Device Location

Room Name/Number

Purpose:

Irrigation

Other

Make

Model Number

Size

Serial Number

Install Date:

Replacement Date:

Test Date:

Type of Reporting

Annual Test

Replacement**

Removal**

New Install**

Describe Additional Repairs (if needed)

Check Valve #1

Check Valve #2

Relief Valve

PSI/DIFF

Did Not Open

Cleaned Unit

Rubber Kit

CV Assembly

OR

Disc

Diaphragm(s)

Seat

Other

Test Done By

First Name

Last Name

Certificate Number

Company Name

Contractor License Number

Company Address

City

State

Zip Code

Company Phone Number

Contact Person

Contact Person Phone Number

Test Done By Signature

Clear

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