533 Bethel School WATER
Issued: i � 6 Finished: C Employee: � Grid map:
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Name: Address: /1 )C- ,r' /
Phone Number (HM) (WK):
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. ItgQair 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: , l c-'477 -
7. If Meter/Service Leak Classify: - City: Customer
,
A. Water Lou (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 C- / ' 5 Reading . 3
B. New Meter # / t ` 1 Reading
C. Old Meter SizeType: l 1 D e " Meter SizeType
E. Type of work performed or findings:
9. If maict or deeps ce repa , describe type of pipe or service line and condition:
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10. Man- hours:1, Crew Members. !/. l 'e(
11. List Materials Used:
12. If you had an iccidetiti:tcident while performing this request. Did you report it? Yes or no
13. Water I:ditties meter inspection: pass or fait
14. How many trips to do task?
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Signature