Coppell CC 1B1-WO010621Issued: ~ ~'~' O / Fuashed: __
Phone N~mber:.(,(~
Check for: Accuracy test: Meter Leak;
Initial meter relocation inspections
Check water pressure:
Re-read
1. ]ilackflow Inso.
2. Reoair 3. ~
Backflow Insp.
Bldlow Cert. Date
Re-Cert. Date
A. Main Line A. Pump A. Linc Locate
B. Valves B. Water Tower B. Line Locate
C. Service Line C. Samples C. Tap
D. Hydrants D. £quipmeut D Excavation
E. Safe~,
5. Reason for failure: A. Elcclxolysis B. New Conslruction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services:~ ~ ~ ~0 - ,,69r3~,. O /
7. If Meter/Service Leak: Classify: - City:
A. Water Loss (estimate): GPM
B. Was Water Metered: Yes
C. Was Customer Notified: Verbally
Customer
8. If Meter Change Out:
A. Old Meter # Reading
B. New Meter # Reading
C. Old Metes Size/Type:
E. Type of work performed or findings:
Fire plug flushing
No
Total Gallons
Doorknocker -
Vehicle/Equil~nent Used
Unit # Miles Hrs Equipment
D New Meter Size/Type
9. If mainline or deep service repair, descffoe type of pipe or service line and condition:
10. Man-hours: Crew Members.
1 1. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utihties meter inspection: pass or fail
14. How many trips to do task?
Si ture