This test report should only be filled out by a certified tester. Visit DPOR Tester Certification Policy Update for testor license requirements. Pass or Fail * - Select -PassFail Type of Test - Select -Annual Test New Construction Retest Customer/Business Name Information Customer Name * Property Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Contact Name * Email Address * Device Information Location of Device * Is this device a new assembly? * Yes No Serial Number of (Old) Replaced Assembly * Type of Inspection * - Select -ResidentialCommercialMulti-Family Type of Service * - Select -Fire LineIrrigationResidential Fire Sprinkler Service Lineother Type of Assembly * - Select -Reduced PressureDouble Gate / Double CheckPressure Vacuum BreakerSpill Proof Vacuum Breaker Manufacturer of Device * Model Number of Device * Serial Number of Device * Size of Device * Comments * Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20222023202420252026 Year Inspection & Test Gauge Measurement Check Valve #1 Static PSID * Check Valve * - Select -Closed TightLeaked Check Valve #2 Static PSID * Check Valve * - Select -Closed TightLeakedPressure Differential Valve Open at PSID * Did Not Open Did Not Open PVB/SPVA Air Inlet Open at PSID * Did Not Open Did Not Open Check Valve Held (PSID) * Leaked Leaked Company & Tester Information Tester Name * Telephone Number * Company Name * Company Telephone * Company Email Address * Tester Certification Number * Test Kit Serial Number * Calibration Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20222023202420252026 Year Certification Statement * By submitting this backflow test report, I hereby certify that I am currently certified as a Backflow Protection Assembly Tester and familiar with the information contained in this form and that to best of my knowledge and believe, such information is true, complete and accurate at the time of this test. Leave this field blank Submit
