Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF]

Annual backflow preventer testing is required by the EPA Safe Drinking Water Act (SDWA) and enforced through state and local cross-connection control programs to protect potable water supplies from contamination due to backpressure or backsiphonage events. The Uniform Plumbing Code (UPC) Section 603 and the International Plumbing Code (IPC) Section 608 mandate the installation, maintenance, and documented annual testing of all backflow prevention assemblies by a certified tester. Facilities that

  • Industry: Building Maintenance
  • Frequency: Annually
  • Estimated Time: 45-75 minutes
  • Role: Building Engineer
  • Total Items: 37
  • Compliance: EPA Safe Drinking Water Act (SDWA) 42 U.S.C. §300f - Cross-Connection Control, ASSE International Standard 1013 - Reduced Pressure Principle Backflow Preventers, ASSE International Standard 1015 - Double Check Valve Backflow Prevention Assemblies, International Plumbing Code (IPC) 2021 Section 608 - Protection of Potable Water Supply, ASHRAE Guideline 12-2000 - Minimizing the Risk of Legionellosis Associated with Building Water Systems

Assembly Identification & Pre-Test Documentation

Record all identifying information about the backflow preventer assembly prior to testing.

  • Has the backflow preventer assembly serial number, make, and model been recorded?
  • What is the type of backflow preventer assembly being tested?
  • What is the nominal pipe size of the assembly being tested?
  • Is the assembly installed in a location that is accessible, protected from freezing, and positioned per manufacturer requirements?
  • What was the date of the most recent prior annual test (if available)?
  • Please capture a photo of the assembly including the identification tag and surrounding installation.

Pre-Test Physical Condition Inspection

Visually inspect the assembly for physical damage, corrosion, and proper installation before initiating functional testing.

  • Is the assembly free from visible corrosion, physical damage, or unauthorized modifications?
  • Are the isolation shut-off valves on both the inlet and outlet in the fully open position prior to testing?
  • Is the assembly discharge port (for RP assemblies) or air inlet (for PVB assemblies) unobstructed and draining freely?
  • Are all test cock ports present, capped, and accessible for attachment of the differential pressure gauge kit?
  • Has the test gauge kit calibration date been verified to be within the required calibration period?

Reduced Pressure Principle (RP) Assembly Test

Perform and record functional differential pressure tests on RP assembly check valves and relief valve.

  • Does this inspection include an RP/RPZ assembly requiring the following RP-specific tests?
  • What is the measured differential pressure across Check Valve No. 1 (First Check)?
  • Did Check Valve No. 1 (First Check) pass the differential pressure test at or above 5.0 psid?
  • What is the measured differential pressure across Check Valve No. 2 (Second Check)?
  • Did the relief valve open at a differential pressure higher than the zone pressure, confirming correct relief valve operation?
  • Did the RP assembly pass all three test criteria (Check 1, Check 2, and Relief Valve)?

Double Check Valve (DC) Assembly Test

Perform and record functional differential pressure tests on DC assembly check valves.

  • Does this inspection include a DC/DCVA assembly requiring the following DC-specific tests?
  • What is the measured differential pressure across Check Valve No. 1 (First Check) of the DC assembly?
  • What is the measured differential pressure across Check Valve No. 2 (Second Check) of the DC assembly?
  • Did both check valves of the DC assembly pass the minimum 1.0 psid differential pressure requirement?
  • Are both isolation shut-off valves of the DC assembly fully functional and providing a water-tight seal when closed?

Water Quality & System Condition Checks

Assess ambient water quality and system conditions that may indicate contamination risks associated with backflow events.

  • Is the water supply pressure at the inlet of the assembly within the acceptable operating range specified by the manufacturer?
  • What is the measured inlet supply water pressure at time of test?
  • Are there any signs of discolored, turbid, or odorous water in the system that could indicate contamination or backflow event?
  • Is the assembly serving any high-hazard cross-connection source such as chemical feed, irrigation with fertilizer injection, or medical equipment?
  • Are there any unauthorized connections, bypass lines, or pipe modifications downstream of the assembly?

Repair, Replacement & Maintenance Actions

Document any repairs performed during the test visit and parts replaced to restore assembly compliance.

  • Did any component of the assembly fail testing and require repair or replacement during this visit?
  • Please describe all repair or replacement actions performed, including parts used and lot numbers where applicable.
  • Was the assembly retested after repairs and did it pass all applicable test criteria?
  • If the assembly could not be repaired on site, has the water service downstream of the assembly been shut off pending replacement?
  • Please capture a photo of any repaired or replaced components after work is completed.

Overall Pass/Fail Status, Reporting & Sign-Off

Record the overall test result, confirm regulatory reporting has been completed, and obtain tester sign-off.

  • What is the overall test result for this backflow preventer assembly?
  • Has the completed test report been submitted to the local water authority or water purveyor as required?
  • Has the building owner or facility manager been notified of the test results and any required follow-up actions?
  • What is the recommended next annual test due date for this assembly?
  • Has a copy of this completed test report been filed in the facility compliance records system for a minimum of 5 years?

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Why Use This Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF]?

This building plumbing backflow preventer annual test checklist [free pdf] helps building maintenance teams maintain compliance and operational excellence. Designed for building engineer professionals, this checklist covers 37 critical inspection points across 7 sections. Recommended frequency: annually.

Ensures compliance with EPA Safe Drinking Water Act (SDWA) 42 U.S.C. §300f - Cross-Connection Control, ASSE International Standard 1013 - Reduced Pressure Principle Backflow Preventers, ASSE International Standard 1015 - Double Check Valve Backflow Prevention Assemblies, International Plumbing Code (IPC) 2021 Section 608 - Protection of Potable Water Supply, ASHRAE Guideline 12-2000 - Minimizing the Risk of Legionellosis Associated with Building Water Systems. Regulatory-aligned for audit readiness and inspection documentation.

Frequently Asked Questions

What is a Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF]?

A Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF] is a standardized inspection form used by building engineer to ensure consistent building maintenance operations. It contains 42 inspection points organized into 7 sections. FREE backflow preventer annual test checklist. Verify cross-connection control & EPA/local code compliance with this PDF template.

How often should I use this building maintenance checklist?

This checklist is designed to be completed annually. Regular use ensures compliance with EPA Safe Drinking Water Act (SDWA) 42 U.S.C. §300f - Cross-Connection Control and ASSE International Standard 1013 - Reduced Pressure Principle Backflow Preventers and helps identify issues before they become problems.

Can I download this Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF] as a PDF?

Yes, you can download this checklist as a FREE PDF for printing or offline use. The checklist includes 42 fields across 7 sections and typically takes 45-75 minutes to complete.

What compliance standards does this checklist cover?

This checklist helps ensure compliance with EPA Safe Drinking Water Act (SDWA) 42 U.S.C. §300f - Cross-Connection Control, ASSE International Standard 1013 - Reduced Pressure Principle Backflow Preventers, ASSE International Standard 1015 - Double Check Valve Backflow Prevention Assemblies, International Plumbing Code (IPC) 2021 Section 608 - Protection of Potable Water Supply, ASHRAE Guideline 12-2000 - Minimizing the Risk of Legionellosis Associated with Building Water Systems. Following these standards protects your organization and ensures best practices.

How do I complete this building maintenance inspection checklist?

Begin by completing the header fields for Test Date & Time, Certified Tester Name, Facility Name / Location, Tester Certification Number, and Work Order / Reference Number. Work through each of the 7 sections, marking items Yes or No as applicable. Add notes for any issues found. The entire process takes approximately 45 to 75 minutes.

What are the key sections in this building maintenance checklist?

This building maintenance checklist is organized into 7 key sections: Assembly Identification & Pre-Test Documentation, Pre-Test Physical Condition Inspection, Reduced Pressure Principle (RP) Assembly Test, Double Check Valve (DC) Assembly Test, Water Quality & System Condition Checks, Repair, Replacement & Maintenance Actions, Overall Pass/Fail Status, Reporting & Sign-Off. Each section contains specific inspection points that building engineer must verify. The structured layout ensures nothing is missed during building maintenance inspections and makes the process efficient, typically taking 45-75 minutes to complete.

Who should use this Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF]?

This checklist is primarily designed for building engineer working in building maintenance operations. However, it is also valuable for quality assurance teams, safety officers, compliance managers, and supervisors who need to verify that building maintenance standards are being met. Organizations of all sizes can benefit from using this Building Plumbing Backflow Preventer Annual Test Checklist [FREE PDF] to maintain consistency and accountability.

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