First United-WO 981217Phone lqumber: (l-h~) ' (WK): -
Check for: Accuracy test:
Meter Leak:
Check water pressure:
Initial meter relocation inspections
Re-read
1. Backflow Inso.
2. Reoair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re-Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
5. Reason for failure: A. Electxolysis B. New Conslxuction 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 forSgrvices:~./4..~ ~-c// ~ ~ ~
7. If Meter/Service Leak: Classify: - City:
A. Water Loss (estimate): GPM
B. Was Water Metered: Yes
C. Was Customer Notified: Verbally
Customer
Fire plug flushing _ Total Gallons
No
Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out:
A. Old Meter # Reading
B. New Meter # Reading
C. Old Meter Size/Type:
Unit # Miles I-Irs Equipment
D New Meter Size/Type
E. Type of work performed or findings:
9. If mainline or deep service repaix, describe type of pipe or service line and condition:
10. Man-hours:
11. List Materials Used:
Crew Members.
12. If you had an accidentlncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
Signature