Nash Manor-CS020715Issued: ~shed: Employee: ~ Grid Map: __
Backflow Insp.
Bkflow Cert. Date
Re-Cert. Date
Phone Number C~: .. 0
Check For: Accuracy Test _ Meter Leak
Initial Meter Relocation Inspections ..
2. R~oaLr
A. Main LIne
B. Valves
C. Service Line
D. Hydrants
Check Water Pressure
Re-Read.
3. Maintenance
A. Pump
B. Water Tower
C. Samples
D. Equipment
E. Safety
5. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation
4. Other
A. Line Locate
B. Line Locate
C. Tap
D. Excavation
D. Other.
6, List of Safety Equipment at Site (if applicable):
A. Barricades B. Cones C. Tape D. Lights E. Other
R-EQUEST FOR SERVICESi /)~=~_~ ~ ~ Z'2~..~ ~" ~
ti' ~_ . .~.~.. /~.~ r.~,,~g
7. If Meter / Service Leak, ClassiC':
City ...
A. Water Loss (e*fimate): 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 of work performed or f'mdings:
_. Fire Plug Flushing ..
YES, NO
VERBALLY,
Customer
Total Gallons
DOORKNOCKER
Reading
Reading.
New Meter Size / Type
(
· /jx'/.,-~ -/
It' mainline or deep service rep, ab, describe type of pipe or service line and con'Trion:, /'
l 1. List materials used:
~-~ ~ . 1_~/~
t2. Il'you had an accident, incident '.vhile peffo~ing ~is request, did ~po~ it. ~S or
13. Water Utilities meter inspection: PASS or FML
14. How many ~ps to do rusk?
7.._35'.-- o z--
NO
Signature