Form 9 — Backflow Test Report

Device Information

Device Serial Number *

Hazard Rating *

Make *

Model *

Installation Location *

Test Results (kPa)

Check Valve 1 *

kilopascals (kPa)

Check Valve 2 *

kilopascals (kPa)

Relief Valve *

kilopascals (kPa)

Accredited Plumber & Council

Tester Name *

Licence Number *

Test Date *

Council

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