Amberpoint-CS020813Phone Number (I~i): (WK): ~/~r.~ c./rq 9 '7 e~-.~'
Check For: Accuracy Test Meter Leak
1. Backflow Insp.
B ackI'low Lnsp.
Bkflow Cert. Date
Re-Cert. Date
Check Water Pressure
Initial Meter Relocat/on Inspections Re-Read
2. Repair 3. Maintenance 4. Other
A. Main Line A. Pump A. Line Locate
B. Valves B. Water Tower B. Line Locate
C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D. Excavation
E. Safety
5. Reason for Failure: 3... Elec~'olysi, B. New Cometion C. Poor Installation D. Other
6, List of Safety Equipment at SiR (if applicable):
A. Barricades B, Cones '5' T.~ D, Lights E. Other
REQUEST FOR SERVICES: a~-~$:~''' /0 ~ ~'/~,
7. If Meter/Service Leak, Classi$': City
A. Water Loss (estimate): GPM __ Fire Plug Flushing
B. Was Water Metered: Y'ES NO.
C. Was Customer Notified: VERBALLY
If Meter Change Out:
A. Old Meter ~
B. New Meter -~
C. Old Meter Size/Type
E. Type of work performed or F.~qdi.ngs:
Customer
~otal Gallons
DOORIQ4OCKER
Reading
Reading
New Meter Size / Type
It' mainline or deep serdce r~a'2-, describe type of pipe or service line and condition:
t0. Man hours:
1l List materials used:
Crew members:
t 2. if you had an acc:denr~incident '~ 5, ile performing this request, did you report
13 Water Utifi'ties meter inspection: PASS or FAiL
!.4. How many trips to do task?
YES
Signature
br NO