• Backflow Meter Test No.

  • Meter Serial Number


  • The assessors believe the information contained within this assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on the condition of the device which was observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.

  • Conducted on

  • Please enter both address location and ... Coordinates


  • Meter Size

  • Type of Use

  • Test Result

  • Fail Reason & Work Completed to Comply

  • Test Result following work

  • By signing this form the user identified as the inspecting plumber confirms they have tested the identified device and made good any defect the device may of had so that it conforms to the Australian Standard AS 3500.

  • Plumber Name & Licence Number:

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