Backflow Pro
Hello, Mario 👋
Humboldt Community Services District
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District / Water Authority
Humboldt Community Services District
Backflow Test Certificate
Backflow Device Information
Type
DC
RP
DCV
DCVA
RPBA
PVB
Device Status
Existing
Removed
New
Replaced
Use Type
Residential
Commercial
Irrigation
Irrigation
Fire
Fire
Initial Test
Check Valve #1 Check Valve #2 Relief Valve Air Inlet
Status
Closed Tight
Leaked
Closed Tight
Leaked
Did Not Open
Opened
Did Not Open
Opened
Held At PSI
Comments
Retest
Check Valve #1 Check Valve #2 Relief Valve Air Inlet
Status
Closed Tight
Leaked
Closed Tight
Leaked
Did Not Open
Opened
Did Not Open
Opened
Held At PSI
Did the Device:
✓ Pass
✗ Fail
Tester Information
Tester
Mario Palmero
Certification #
133
Cert Expiration
7/08/2027
Test Kit Serial #
330917
Calibration Date
5/6/2025
Phone
707-499-5900
Signature
Sign here with your finger
I certify all information on this report is true and accurate, acknowledging that incomplete reports will not be accepted.
Send To
Auto-filled from district
Return Completed Test Report to:
Humboldt Community Services District · P.O. Box 158, Cutten, CA 95534
Your Info
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Customer List
Data
Downloads a copy of this app with all your test records, archives, customers, and settings baked in. Open the backup file on any computer to restore everything.
Drafts
Export
📄 Test Records
👥 Customer List
Exports all customers with address, owner, district, device info and last test date.
Columns included in test export
✓ Address
✓ Owner / Location
✓ District
✓ Test Date
✓ Result
✓ Serial No.
✓ Manufacturer
✓ Model & Type
✓ Size
✓ CV1 Status & PSI
✓ CV2 Status & PSI
✓ Relief Valve
✓ Air Inlet
✓ Retest readings
✓ Comments
✓ Pass / Fail
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