552 Arbor Brook •
•
WATER •
Issued: 14 1 24 Finished: • el f "Lq Employee: Grid map:
Name: Address: S 5 7 A & 2 134, .�
Phone Number: (T M) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
5. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services:
7. If Meter /Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # C! 0 5 8`S ai Reading 177,6
B. New Meter # Zip 413002 3 Reading 000 60
C. Old Meter SizeiType: 2 f C SBP /1/4( S 4 D New Meter Size/Type fV 4 'r 7 C
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members. • .roilL
11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task? C �
Signature 41 /`.4