City of Houston - Backflow Assembly & Test Report Form
Name of Property: 
Property Address: 
City, State, Zip: 
 
Key Map#: 
-Phone#: - 
Same as above:  Mailing Address: 
Contact Name: 
Type of Assembly
 
 
New Existing Replaced:  (Old serial number replaced)
 
 
 Reduced Pressure Principle (RP) Reduced Pressure Principle Detector (RPD) Pressure Vacuum Breaker (PVB)
 
 
 Double Check Valve (DCV) Double Check Valve - Detector (DCD) Spill Resistant Pressure Vacuum Breaker (SVB)
 
 
Manufacturer: Model #: 
 
 
Size: Serial Number: 
 
 
Serving/Location: Date Installed: N/A  
 
Is the assembly installed in accordance with manufacturer recommendations and/or City's Uniform Plumbing Code?  Yes No
 
 
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER & SVB
 
Double Check Valve Assembly
RELIEF VALVE
AIR INLET
CHECK VALVE
 
CHECK VALVE #1
CHECK VALVE #2
 
 
 

INITAL
TEST
D. C. Closed Tight 
RP  PSI
Leaked 
Closed Tight 
 PSI
Leaked 
Opened At
 PSI
Did Not Open 
Opened At
 PSI
Did Not Open 
Held At
 PSI
Leaked 
REPAIRS
MATERIALS
USED

FINAL
TEST
D. C. Closed Tight 
RP  PSI
Closed Tight 
 PSI
Opened At
 PSI
Opened At
 PSI
Held At
 PSI
Test Gauge Used: Make/Model S/N: Calibration Date:  {Tested Annually}
Remarks: 
The above is certified to be true at the time of Testing
Backflow Test Status  Pass  Fail
CT's Firm Name: 
Tester Name: 
Firm Address: 
City Tester No.: 
Test Date: 
Firm Phone #:
C.O.H C.C.C Witness: