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Sample company (fictional) · Backflow TestingDraft generated Oct 30, 2026

Backflow test report, water system copy

Aug 20, 2026

Record

Serial number	SE-4137
Type	RPDA (reduced pressure detector)
Location on the property	Loading dock
Size	8.25 in
Manufacturer	Tollin Industrial
Model	MO-4137
State	Washington
Hazard served	Hazard served 2
Hazard level	Non-health or low hazard
Protection	In-premises (a fixture or system)
Service connection	Non-residential
Install date	Aug 18, 2026
Installation	New
Serial number of the assembly it replaced	RE-4137
Water system	Water system 2
Water system ID	Water system ID 2
On a fire line	No
On a non-potable supply	No
Detector bypass: make and model	BY-4137
Detector bypass: serial number	BY-4137
Detector bypass: size	2.75 in

Test date	Aug 20, 2026
Reason for the test	New installation
Result	Failed
Tester	Jordan Pike
Licence or certificate number	TE-4137
Test kit serial number	KI-4137
State	Washington
Licence or certificate expires	Sep 4, 2026
Tester phone	555-0111
Test kit make and model	KI-4137
Test kit last accuracy check	Feb 19, 2026
Gauge kept for	Non-potable water
Sent to the water system on	Aug 20, 2026
Sent through	Email
Owner copy sent on	Aug 20, 2026

Make and model is an approved assembly for this use	Pass
Installed in the orientation its approval allows	Fail
Installed as the manufacturer and the local code require	Pass
RP and RPDA: an air gap below the relief valve discharge	Pass
Test cocks and shutoff valves present and working	Pass
Reachable for testing and repair	Pass
Assembly type suits the hazard it protects	Pass

Reading	Value	Result
RP, RPDA: first check held at Washington DOH memo to certified testers: USC Tenth Edition field test procedures (2011) (https://doh.wa.gov/sites/default/files/legacy/Documents/4200/bats.pdf), checked 2026-10-28	8 psid	Pass
RP, RPDA: relief valve opened at Washington DOH memo to certified testers: USC Tenth Edition field test procedures (2011) (https://doh.wa.gov/sites/default/files/legacy/Documents/4200/bats.pdf), checked 2026-10-28	3.8 psid	Pass
RP, RPDA: relief valve Washington DOH memo to certified testers: USC Tenth Edition field test procedures (2011) (https://doh.wa.gov/sites/default/files/legacy/Documents/4200/bats.pdf), checked 2026-10-28	Opened	Pass
First check valve	Closed tight	Recorded
Second check valve	Closed tight	Recorded
DC, DCDA: first check held at	Not taken	Recorded
DC, DCDA: second check held at	Not taken	Recorded
PVB, SVB: air inlet opened at	Not taken	Recorded
PVB, SVB: air inlet	Opened fully	Recorded
PVB, SVB: check valve held at	Not taken	Recorded
Detector bypass check held at	Not taken	Recorded
Line pressure	Not taken	Recorded

The signature drawn on the phone at the job prints here.