PA9901-WO010822Phone ~ff~mber:
WATER
Employee~ Grid map:
(wi): ~7~- o 7Ya - 77~
Check for:. Accuracy teat:
Initial mete:' relocation inspeetioms
Meter Leak: Check water pressure:
Re-read
2. Reoair 3.~ 4. Other
Backflow In~p.
Bldlow Cer~ Date
Re-Cert. Date
A. Maia LEe A. Pum:p A. Mae Locate
B. Valves B. Water Tower B. Lbae Locate
C. Service Line C. Samples C. Tap
D. Hydrants D. Equ!pme=t D Excavation
£. S al'eh/
5. Reason for/'ailu~e: A. Electrolysis B. New Con.,m'uc~ion C Poor Instalh,~on D. Other
6. List of sdety equipmem at gte R'applicable:
A. ~uricade.s B, Codes C. Tnl~ D. Li/hte E. Other
Request for Services: ~ ~~
7. If Meter/Set'vice Leak: Cla. sii.,~,,': - City:
Cllstomer
A. Water Loss (estimate): GPM __
B. Wss Water Mete~d: Yes
C. Wu C~tomer Notified: Verbally
F~e plug flushiag
No
Total Gallons
Doork~ocker -
8. If Meter C"n_aage Out:
Vehicle/Equipment Used
Unit # .Miles Hrs Equipment
A. Oki Meter # Reading
B. New Meter # Reading
C. Old Meter Size/Type:
E. Type of work perfomed or findings:
D New Meter Sine/Ty~e
9. If mni. llne or deep service rr-~/r, descn'be tlqae of pipe or service llne and conditio,¥
10. M,-hour~: Crew Mere
11. L~tMateha5 Used:
12. If you had an ac¢iden~Incideat while performing this request. Did you repor~ it? Yes or no
13. Water Utiliues meter/nspecr~on: p~ss or fail
14. How many ~p~ to do
Signature