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Backflow Testing and Inspection Report
Backflow Testing and Inspection Report
$0.00
To apply for this permit, enter the required information below and click "Next".
Required fields
Site Details
Site Name / Occupancy
Site Usage
PID
Telephone
Site Address
Please enter your postal code to begin
PO Box
PO Box
Country
Canada
United States of America
Postal code
Zip Code
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
State
Maine
City
City
Street Number
Civic number suffix
Street name
Street name
Unit type
N/A
Apartment
Suite
Unit
Room
Unit
Property Owner Information
Company name
First name
Middle name
Last name
Email
Phone (Primary)
Phone (Alternate)
Mailing Address
Please enter your postal code to begin
PO Box
PO Box
Country
Canada
United States of America
Postal code
Zip Code
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
State
Maine
City
City
Street Number
Civic number suffix
Street name
Street name
Unit type
N/A
Apartment
Suite
Unit
Room
Unit
Tester Details
First name
Last name
Licence Number
Company Name
Company Email Address
Telephone
Test Kit Details
Make of Test Kit
Model Number
Serial Number
Calibration Due Date
Test Details
Assembly Type
Double Check Valve Assembly
Reduced Pressure Principle
Pressure Vacuum Breaker (PVB)
Spill Resistant PVB
Make of Assembly
Model Number
Serial Number
Size
Location of Assembly in Building
Level of Protection
Premise
Area
Zone
Individual
Type of Test
Initial
Repair
Annual
Date of Test
Line Pressure at Time of Test
kPa
psi
Initial Test
Pass
Fail
Final Test
Pass
Fail
Comments - Reason for failure (if apparent)
Component Test Details
Assembly Type
Double Check Valve Assembly
Reduced Pressure Principle
Pressure Vacuum Breaker (PVB)
Spill Resistant PVB
Component
Test
Initial Test
Final Test
Relief Valve
Differential pressure relief valve opened at (2 PSID min)
Shut Off Valve # 2
Leaked
Closed Tight
Leaked
Closed Tight
Reset
Check Valve
Closes tight in direction of flow (1.0 PSID min)
Check Valve # 2
Differential pressure in direction of flow (1 PSID min)
Check Valve # 2
Reverse Flow
Leaked
Closed Tight
Leaked
Closed Tight
Reset
Check Valve # 1
Differential pressure in direction of flow (1 PSID min)
Check Valve # 1
Leaked
Closed Tight
Leaked
Closed Tight
Reset
Check Valve # 1
Pressure differential across 1st check
Buffer
Pressure drop across 1st check minus opening point of relief valve (min. 3 psi)
Air Inlet Valve
Opening Differential (1.0 PSID min.)
Repair Details
Assembly Type
Double Check Valve Assembly
Reduced Pressure Principle
Pressure Vacuum Breaker (PVB)
Spill Resistant PVB
Differential Pressure Relief Valve
Cleaned
Replaced
Disc Upper
Diaphragm Sm
Diaphragm Lg
Disc Lower
Upper
Upper
Spring
Spacer
Lower
Seat
Other
Other
Check Valve 1
Cleaned
Replaced
Disc
Pin Retainer
Spring
Hinged Pin
Guide
Diaphragm
Seat
Other
Other
Check Valve 2
Cleaned
Replaced
Disc
Pin Retainer
Spring
Hinged Pin
Guide
Diaphragm
Seat
Other
Other
Shut Off Valve 2
Cleaned
Replaced
Disc
Seat
Other
Other
Check Valve 1
Cleaned
Replaced
Spring
Guide
Pin Retainer
Hinged Pin
Seat
Diaphragm
Disc
Other
Other
Check Valve 2
Cleaned
Replaced
Spring
Guide
Pin Retainer
Hinged Pin
Seat
Diaphragm
Disc
Other
Other
Cleaned
Replaced
Vent Spring
Poppet
Retainer
Spring
Disc
Guide
Vent Disc
Other
Other
Signature of Applicant
Signature
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I understand and agree
Checking this box and electronically sending this form constitutes your electronic signature.
Date
2026-03-30 [20260327.1 (124266)]
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