Lynnwood, WA · Snohomish County
Backflow Preventer Inspection and Field Test Report
Backflow assembly testers use this report to record an inspection, field test, repairs, and test results for a Lynnwood water service.
What this form is
This report records an inspection and field test of a backflow assembly, or an inspection of an air gap or AVB. The tester fills in information about the water service, facility, assembly, test results, repairs, and test equipment. It includes a certification that the inspection and test were completed using the stated procedures and equipment, and that the report information is accurate.
Who needs it
A backflow assembly tester completing an inspection or field test, or a person inspecting an air gap or AVB, uses this report.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This report is signed without a notary; it has no notarized or sworn attachment, so the tester signs and dates the report.
How to submit this form
- 1
Download The Report
Download the Backflow Preventer Inspection and Field Test Report PDF.
- 2
Complete The Report
Enter the service, facility, assembly, inspection, test-result, and test-equipment details requested on the form.
- 3
Record Repairs And Certification
Record any cleaning, repairs, or parts and complete the tester certification and signature fields.
- 4
Submit To The City
Submit the completed report to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What does the Backflow Preventer Inspection and Field Test Report record?
- It records service and assembly details, inspection and field-test results, repairs or parts, test equipment information, and the tester’s certification.
- Who uses this report?
- A tester uses it to document an inspection and field test of a backflow assembly, or an inspection of an air gap or AVB.
- Do I need a notary for the Backflow Preventer Inspection and Field Test Report?
- No. The report is signed without a notary and has no notarized or sworn attachment; the tester signs and dates the report.
- How do I submit the Backflow Preventer Inspection and Field Test Report?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Backflow Preventer Inspection and Field Test Report doesn’t need a notary — but if you have another Lynnwood form that does, a commissioned online notary can help.