Boundary backflow device test certificate

Important information
Complete this form to show that the boundary backflow device on the property specified below has been maintained and tested as required under the Health Act 1956 and the Health (Drinking Water) Amendment Act 2007.

*Mandatory fields

1. Your details

2. Backflow device details

3. Test details



Reduced pressure devices
Double-check devices
Relief valve
1st check
2nd check
Initial test
Repairs and materials used
Test and repair

4. Authorisation

To be completed by an independently qualified person (IQP). By submitting this form, I declare that the information on this test certificate is true and correct.

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