Freeport NIP(2.3)-CS 961105~hone N~e~: (~): (~) -
T~e for ~a~er ~oca~e
Check for: ~:u~y ~: M,~r ~: ~.~ w,~r p~:~ ~ ~ ~ ~,~ ~on _
X.Backflow InsD~ 2. Repai~ 3. ena ce
Backflow Insp. A.Main Line A.P~ps A.L~m ~ca~e
B.Valves B. Wa~er Tower B. Ins~c=ion
Bkflow Cer=. Date C. Service Line C. S~ples C. Tap
D. Hydr ant s D. E~i~ent D. ~cavat ion
Re-Cert. Date E. Safety
5. Reason for failure:
A. Electrolysis B. New construction
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
C. Poor installation
D. O~her
Request for Serviceman:
7.If Me=er/Service Leak:
A.Water Loss ~ma~): GPM
B.Was Wa=er Metered:
C.Was Customer Notified:
Classify - City:
Fire plug flushing
Yes No
Verbally DOORKNOCKER
8.If Meter Change Ou=:
A.Old Meter~.
B.New Meter~.
Reading
Readinq
Customer:
Total Gallons
Vehicle/Equipment Used
Unit # Miles Hrs Equip
C.Old Me=er Size/Type:
E.Type of work performed or findings:
9.If mainline or deep service repair,~---'~ ~L-~e ~ pi.~ or service
10.Manhours: /, ~ Crew members: /~~--
l~.Lls~ MaCeri&la Used~
12.If you had an acciden=/inciden= while performing ~his request. Did~u rel~C/.)/.Lt? ~e or no
13.Wa~er U~ili~le~ ~ter ~nspec~lont pass o~ fail / ~
14.How many =rips 2o do 2ask2 ~ ~ ~~~