# Backflow Assembly Self-Check

**Frequency:** Quarterly

A basic visual check between your required annual test. Testing the assembly itself requires a certified tester and gauge -- this is only a look-and-listen check.

## Checklist

- [ ] Assembly is accessible and not blocked by storage or landscaping
- [ ] No visible leaks at the assembly or surrounding piping
- [ ] Shutoff valves appear undisturbed and in the correct position
- [ ] No unusual discharge from the relief valve
- [ ] Current test tag/certification is present and legible

## Notes

Anything that didn't look right, or any area you couldn't access this time:

_____________________________________________

**Checked by:** ______________________  **Date:** ____________

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Backflow Assembly Self-Check — adapted from a free checklist by Rogers Fire Protection Co., https://rogersfp.com/resources/checklists

Free to copy, adapt and use, including commercially. Please keep the attribution line.

This is a self-check for building staff. It does not replace the professional
inspection your local authority requires.