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528 Cromwell WATER Issued Finished /2- - 1 Employee `/ � Grid map Name: Address: 5 ' © w E ?hone Number: (HM): (WK): Time for Water locate Check for: Accuracy test:_ Meter Leak:_ Check water pressure:_ Initial meter relocation inspection Re __ 1.Backflow Insp. 2. Repair 3.Maintenance 4.Other Backflow Insp. A.Main Line A.Pumps A.Line Locate B.Valves B.Water Tower B.Inspection Bkflow Cert.Date C.Service Line C.Samples C.Tap D.Hydrants D.Equipment D.Excavation Re -Cert. Date 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 G , Request for Serviceman: Y)A. ER 1 £ S7 LWK ' P a - a ` I 7.If Meter /Service Leak: Classify - City: Customer: A.Water Loss (Estimate): GPM Fire plug flushing Total Gallons 3.Was Water Metered: Yes No C.Was Customer Notified: Verbally DOORKNOCRER Vehicle /Equipment Used 8.If Meter Change Out: 1 Unit i Miles Hrs Equip a. Old Meter# 2:7, e3 S ' Reading / 0 � I B. New Meter* ?. 1 of-4s-1 Reading C.Old Meter Size /Type: D. New Meter Size /Type P1J - S i ' // E.Type of work performed or findings: C C` 9.If mainline or deep service repair, describe type of pipe or service line and condition: 10.Manhours: W S J Crew members: G'./ 11.List Materials Used: 12.If you had an accident /incident while performin • request. Did you report it? yes or no 13.Water Utilities meter inspection: pass o f 14.How many trips to do task? Signature