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0828 WATER Issued Finished Employee 31)V'.. Grid map Name: Address: 7 10 i�t.. ?hone Number: (HM): (WK): Time for Water locate Check for: Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspection Ro-read_ 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 5. List of safety equipment at site if applicable: A. Barricades 3. Cones C. Tape ` r.. D. Lights E. Other e Rrniest for Serviceman: t"�,r.A 5 •-ke A'''N � I 9023 2. 2t* 77.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 DOORKNOCXER Vehicle /Equipment Used 3.If Meter Change Out: � Unit 0 Miles Hrs Equip =..Old Meter# /90 Reading [T L 10 6 al / C . 2 -©S K 3. New Meter # z l Y CI '` Reading S / C.Old Meter Size /Type: �// 1 D. New Meter Size /Type � � /, E.Type of work performed or findings: 9.If mainline or deep service repair, describe type of pipe or service line and condition: 10.Manhours: 0 Crew members: 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? Signature (1\..)1._•-.)