StamparioBackflow test report form
A one-page test report for RP, DC, PVB and SVB assemblies, laid out like most purveyor forms. Print it for the truck, or fill the same report on your phone and send a signed PDF on site.
Rather fill it on your phone? Try it free in Stampario: the customer signs on screen and gets the PDF before you leave.
What the form records
Reason for the test (annual, new install, after repair), assembly type, make and model, serial number, size and location. Then the initial test: check valve #1 and #2 in psid, whether check #1 closed tight, the relief valve opening point for RPs, or the air inlet and check readings for PVBs and SVBs. A failed test adds repairs and a retest.
What purveyors usually reject
Missing serial numbers, a test kit without a calibration date, and no tester certification number are the common reasons a report comes back. All three have their own line on this form.
Use your purveyor’s form when required
Many utilities publish their own form or require a portal. This form follows the common layout, but if your purveyor insists on theirs, use it for filing and give the customer this copy.
- 01Reason for test
- 02Replaced assembly serial #
- 03Water purveyor
- 04Water account / meter #
- 05Meter reading
- 06Utility device / hazard #
- 07Type of service
- 08Make & model
- 09Assembly type
- 10Serial number
- 11Size
- 12Location of assembly
- 13Bypass meter reading / serial
- 14Line pressure
- 15Line pressure stable
- 16Shut-off valve #1
- 17Shut-off valve #2
- 18Check valve #1
- 19Relief valve opened at
- 20Check valve #2
- 21Air inlet opened at
- 22Check valve held at
- 23Check valve #1
- 24Check valve #2
- 25Relief valve did not open
- 26Air inlet opened fully
- 27Initial test result
- 28Repairs and parts
- 29Repair details
- 30Check valve #1
- 31Relief valve opened at
- 32Check valve #2
- 33Air inlet opened at
- 34Check valve held at
- 35Retest result
- 36Tester certification #
- 37Certification expires
- 38Test kit
- 39Test kit serial
- 40Test kit calibration date
- 41Results filed with the utility on
- 42Notes & recommendations
Plus customer, service address, date, time on site, technician, photos and signatures.
The same form, finished on site
- Last visit’s equipment details are already filled in
- Readings, photos and signatures on one PDF with your logo
- The customer gets it by email before you leave
- The next due date lands on your call list
About this template
Is this form accepted by my water purveyor?
It contains the fields found on typical purveyor forms, but each purveyor decides what it accepts. Check their requirements; some only accept their own form or a portal submission.
How long should I keep backflow test records?
Retention rules vary by state and purveyor; many testers keep at least three years. Keeping them in the app means they are searchable by address and assembly.
Fill the backflow test report form on your phone
Free for 5 reports a month. No card. Your logo on every PDF from the first one.