Compliance · Certified Testers

Backflow Test Report

Customers with a backflow-prevention assembly (commercial services, fire lines, and irrigation systems) are required to have it tested by a certified tester on a recurring basis. After completing the test, use this form to submit the results and attach the signed report. Questions? Call our office at 913-724-1800.

Customer / facility

Business / property nameWater account #Contact nameContact phoneEmail (for confirmation)Service addressCityStateZIP

Backflow assembly

Device typeLocation on premisesManufacturerModelSizeSerial numberHazard / use (optional)

Test result

Test date *Result *

Repairs / corrective action were made during this testNotes

Certified tester

Tester name *CompanyCertification / tester #Test kit #

Attach the signed report *

Upload the completed, signed test report (PDF or a clear photo). This is the official record we keep on file.