Backflow Prevention Test Report

1. Property Details

• Property Owner/Company Name: [Enter Full Legal Name]
• Property Address: [Enter Street Address, Suburb, State, Postcode]
• Water Authority/Account Number: [Enter Authority Name and Account Number]
• Test Date: [DD/MM/YYYY]

2. Device Details

• Device Location: [Describe location, e.g. 'Main water meter at front boundary']
• Device ID/Serial Number: [Enter Serial Number from the device body]
• Device Type: [Select: RPZD / DCV / Dual Check Valve / Air Gap]
• Size (mm): [Enter Size, e.g. 20mm, 25mm]
• Manufacturer: [Enter Brand Name]
• Model: [Enter Model Number]
• Year of Manufacture: [Enter Year]

3. Test Equipment Details

• Tester Name: [Enter Full Name of Licensed Plumber]
• Licence Number: [Enter State Plumbing Licence Number]
• Test Gauge Serial Number: [Enter Gauge ID]
• Gauge Calibration Due Date: [DD/MM/YYYY]

4. Test Results (RPZD)

• Inlet Pressure (kPa): [Enter Reading]
• Zone Pressure (1st Check Closed) (kPa): [Enter Reading]
• Relief Valve Opening Pressure (kPa): [Enter Reading]
• Relief Valve Closing Pressure (kPa): [Enter Reading]
• Check 1 (Shut-off) Pressure (kPa): [Enter Reading]
• Check 2 (Shut-off) Pressure (kPa): [Enter Reading]

5. Test Results (DCV)

• Inlet Pressure (kPa): [Enter Reading]
• Check 1 (Shut-off) Pressure (kPa): [Enter Reading]
• Check 2 (Shut-off) Pressure (kPa): [Enter Reading]

6. Outcome

• Test Result: [Select: PASSED / FAILED]
• Reason for Failure (if applicable): [Describe fault, e.g. 'Relief valve failed to seat']
• Repair Action Taken: [Describe repair or replacement details]

7. Declaration I, the undersigned, certify that the above information is true and correct. I tested the device using a gauge that is currently calibrated. The test was conducted in accordance with AS/NZS 3500.1.

• Plumber Signature: __________________

• Date: [DD/MM/YYYY]

• Property Owner Acceptance: __________________

• Date: [DD/MM/YYYY]