Transcription of DEKALB COUNTY
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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 Serial Make: _____ Model: _____ Size: _____ Type: RPP DC DCDA DETECTOR CHECK (BYPASS) PVB RPDA Date Installed: _____ Location on property: _____ New Orientation Use Protection Existing Vertical Up Domestic Containment Previous assembly
Previous Assembly Serial No: _____ ☐ Vertical Down ☐ Fire ☐ Isolation ☐ Horizontal ☐ Irrigation Initial Test Results Repairs/Comments Re-Test Results
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