Backflow Preventer Test Form


Download Form (PDF, 240KB) Instructions and
Example of Completed
Backflow Test Form (PDF, 334KB)

  1. Test reports can be picked up at the Lincoln Water System office, 2021 North 27th Street, or downloaded here(PDF, 240KB).
  2. Fill out the test report completely, especially address, phone, email and company name. Complete the fields in the PDF form(PDF, 240KB), or write legibly in ink if using a paper form.
  3. Start at top with the Customer and Device Information. Fill out all fields.
  4. Device Location of the assembly is very important. Be specific. (Example: Boiler room NE Corner, Basement-Room 117)
  5. Enter information for Type of Protection, Type of Assembly, Serial #, Size, Manufacturer and Model # of Assembly.
  6. Indicate if the test is New, Annual, Repair, Replacement (Provide old serial #), Retired (means it has been removed permanately) or is Out of Service (temporarily no water, building under repairs etc.) If a test Fails, check what failed and any applicable repairs to be done in the repairs Section of the form.
  7. Enter the readings on the test report. The readings need to fall within the test procedure’s guidelines. (LWS manually reads the reports before we enter them into our system. LWS personnel will not adjust your readings; you will be asked to review your records or retest the assembly if you transferred the wrong readings).
  8. Please complete all fields in the Tester Information section.
  9. Report must be returned within 30 days of test. Please email PDF to backflow@lincoln.ne.gov, fax to 402-441-8003, or send via postal mail to Lincoln Water System Backflow, 2021 N 27th St, Lincoln, NE 68503.
  10. Report copies:
    • For downloaded PDF forms, please save a copy for your records and share with the business.
    • For paper forms provided by LWS, white copy: send to Lincoln Water System, yellow copy: keep for your records, pink copy: provide to business.
  11. Do not hesitate to call. We will supply you with the number of assemblies in a building, their location, serial number, etc. if you are unable to obtain this information from the customer.

SEE EXAMPLE of a Completed Backflow Test Form(, 0B). If Test Forms are not completed correctly, they may be returned.

If you suspect a cross-connection, call us immediately and we will investigate.

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