Backflow Prevention Test Form

Job:

Owner / Site Info Owner/Occupier:
Address:
Suburb:
Post Code:
Business Type:

Test Details Authorised Tester Name:
License No:
Test Date:
Permission received to turn off water:
Y N

Initial Test? Annual Test?
Test Kit Serial No:
Calibration Date:

Device Info Main Meter No:
Device Protection Type:
Zone Protection Containment Protection Individual Protection Device Location:
Device Type:
Make: Model:
Size (mm): Serial No:

Strainer Strainer Installed
Strainer Cleaned

Test Results

	Check Valve 1	Check Valve 2	Downstream Isolation Valve	Relief Valve
☑ Closed Tight
☑ Leaked
kPa

Single Check Valve Testable - SCVT / SCDAT Fire Service Meter No (if applicable):

Serial No:

Upstream Isolation Valve:
Closed Tight Leaked
kPa:

Downstream Isolation Valve:
Closed Tight Leaked
kPa:

Main Check Valve:
Closed Tight Leaked
kPa:

By Pass Dual Check Valve:
Closed Tight Leaked
kPa:

SCDAT Pressure Difference (kPa):

Device Compliance Installation complies with AS/NZS3500.1: Yes No

Device Test Results: Pass Fail

Comments / Remarks

Certification Date:

Cert Signature: To sign, please download the PDF and use Adobe Acrobat or an approved digital signing tool.