DEKALB COUNTY
DEKALB COUNTY DEPARTMENT OF WATERSHED MANAGEMENT 4572 MEMORIAL DRIVE DECATUR, GEORGIA 30032 (404) 687-4075 BACKFLOW PREVENTION assembly TEST & MAINTENANCE REPORT (PLEASE PRINT) Tester Tester Name: ______________________________________ Telephone Tester Certification:______________________ Certificate Expiration Date: ___________________ Tester certifies that this assembly has been tested with the above listed procedure and verifies that isolation valves were returned to pre-test orientation. Test Procedure: ______________________________________ Signature: ________________________________________ ________ DATE:______________________Revision 2/17 Account Contact Name: _______________________________________ Phone # _________________________________ Business Name: ___________________________ Meter #________________ Meter Reading: _______________ Mailing Address: ________________________________________ ______________________________________ Service Address: _______________________________City: ________________ ST:________ Zip: _____________ assembly assembly Test Results: Pass Fail assembly S
Previous Assembly Serial No: _____ ☐ Vertical Down ☐ Fire ☐ Isolation ☐ Horizontal ☐ Irrigation Initial Test Results Repairs/Comments Re-Test Results
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