CF TownC P/C-WO 961205Phone Number: (HM):
Check for: A~m~y ~t:
Backflow Inep.
Bkflow Cer=.Da=e
Re-Cer~. Dare
5. Reason f~r failure:
Molar I.mdc C~k wator p~smre: Initial motor t~lo~afion ~
2. RePair
A.Main Line
B.Valves
=.Service Line
D.Hydrants
A.Pumpe
B.Water Tower
=.samples
D.Equipment
E.Safety
A. Electrolysis B. New cons=--ac=ion
6. Lis= of safety equil)men= at sire if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Re.cues= for Serviceman: "~..~.~_~. N =~ ~.,~)~.~k ~
4.Other
A.Line Locate
B.Inipe~'~ion
=.Tap
D.Exoava=ion
C. Poor ins=ails=ion
D. Other
7.If Meter/Sea;ice Leak: Classify - City: __
A.Water Loss (r~a~: GPM Fire plug flushing
3.Was Water Metered: Yes No
G.Was Customer Notified: Verbally DOOlt~o~u~A __
S.If Me=er Change Our:
A.Old Meter~ Reading
B.New Me=er~ Reading
To=al Gallons
Vehicle/Equipment Used
Unit # Miles Hfs Equip
=.Old Me,er Size/Type:
.~~work performed or findings: ~.
!
D. New Me=er Size/Type
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: r ~) Crew
12.If you hsd an accident/incident while perfoNming thil ~quilc. Did you re~ £=~ yll or no
13.Water Utllitiel meter lnspectionz pall or fall
lC.How many tripe =o do task?
Signature