PA9901-WO020723Check For: Accuracy Test Meter Leak Check Water Pressure
Backflow [nap.
Bkflow Cert. Date
Re-Cert. Date
Initial Meter Relocation Lnspections . Re-Read
2. p.e~air 3. Maintenance 4. Qtheg
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: A. Electrolysis B. New Construction 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: ~
7. If Meter / Semce Leak, Classi~': City
A. Water Loss (estimate): GPM
B. Was Water Metered:
C. Was Customer Notified:
If Meter Change Out:
A. Old Meter #
B. New Meter #
C. Old Meter Size / Type
E. Type o f work performed or findings:
Customer
Fire Plug Flushing. Total Gallons
YES NO
VERBALLY DO0RIGNOCKER,
Reading
Reading
New Meter Size / Type
It' mainline or deep serVme repa'.r, aescnoe type or pipe or servtce line aha conut , /~'
[0. Man hours:
1 [. List materials used:
Crew members:
12. it'you had an accident/incident while performing this request, did you repor~ it?
13. Water Utilities meter ~,.apection: PASS or FAIL
t4. How many trips to do task?
YES br NO
Signature