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Backflow Test Report Forms

Preprinted backflow test report forms, containing the make, model, size, serial number and site location, can be obtained for any existing backflow by contacting the Water Quality Specialist. Otherwise, the tester may submit results for any backflow assembly test by using the City of Fullerton’s standard blank test report form available online.


Backflow Test Form (pdf)


Records of such tests, repairs and overhauls must be provided to the City of Fullerton and the County of Orange Health Care Agency for their respective permanent files.


Mail the original completed test report form to:


City of Fullerton

Engineering Department

Attention: Water Quality Specialist

303 W. Commonwealth Ave

Fullerton, CA 82832


Mail a copy of the completed test report form to:


County of Orange Health Care Agency

Water Quality Section

1241 E. Dyer Rd., Suite 120

Santa Ana, CA 92705-5611

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