Ashton Ridge-WO 961211 (2)Phone Number: (HM):
check for: A~curecy ~e,t:
Backflow Insp.
Employee-~-~
Address
Bkflow Cer=.Da=e
D.Hydrants D.Equipment
Re-Car=. Da=e E.Safe=y
5. Reason fgr failure: A. Electrolysis B. New cons=ruo=ion
&. Lis= of safe=y equipmen= at si=e if agplicable:
A. Barricades B. Con~ C. Tape D. LighTs E~ ~
C. Poor ins=al!a=ion
D. O=her
T.If Me=er/Ser';ice Leak: Classify - Ci=y:
A.Wa=er Loss ('F.~ma~}: GPM Fire plug flushing __
~.Was Wa=er Me=ered: Yes No
z. Was Cue=omar No=iliad: Verbally __ DOOI~KNOC~E]t __
8.If Me=er Change
A.Old Me=er#. Reading
B.New Me=er#. Reading.
Total Gallons
Vehicle/Equipmen= Used
Uni= # Milee Hfs
Equip
c.Old Meter Size/T~e: D. New Mece~ize/T~e
9.If mainline or deep service repair, describe =y~e ~f pipe or service line and condi=ion:
10.Manhours~ Crew
11.Lle~ Ma~ari&le Used:
12.Zf you had an acciden=/lnciden= whale perfozming ~his requee:. D~ou rep~ it?.yee or no
14.How many r. ripe r.o do t:aek? Stgn&tur~