Water and Sewer Apps

Backflow Prevention Inspection Form

Backflow devices are pivotal in preventing contaminated water or chemicals from flowing back into the main drinking water distribution supply. Use the Backflow Prevention Inspection Form to conduct periodic inspections and to ensure proper installation and operation of backflow prevention devices. Document up-to-date information on device serial numbers, backflow hazard type, GPS coordinates of the preventer location, and more to ensure the safety and quality of water supply in the event of unexpected changes in water pressure. Customize this form entirely to accommodate your specific inspection requirements. This app works in both on and offline environments.

Backflow Prevention Inspection Form iPhone, iPad Backflow Prevention Inspection Form Android Backflow Prevention Inspection Form Web, Desktop
Backflow Prevention Inspection Form

General

PWS ID

Water System Name

File #

Facility Name

Property Type

Address

Contact Person

Phone

Email

Hazard Type

Preventer Physical Location

Preventer Status

Old S/N

Confined Space

Assembly Make

Model

Serial #

Size

USC-Approved

Proper Install

Proper Orientation

Initial Test

Initial Test

DCVA

Check Valve 1

Leaked

Check Valve 2

Leaked

Cleaning, Repairs, & Parts

Cleaned or Repaired

Parts

RPBA

Relief Valve

Opened

Check Valve 1

Opened

Check Valve 2

Approved Air Gap

Cleaning, Repairs, & Parts

Cleaned or Repaired

Parts

PVBA/SVBA

Air Inlet Valve

Check Valve Leaked

Cleaning, Repairs, & Parts

Cleaned or Repaired

Parts

Air Gap Inspection

Supply Pipe Diameter

Air Gap Separation

Signature