SC-Town Center E8-WO 960726Time for Water locate
Check for: A¢¢u~cy~:__
Backflow Insp.
Bkflow Cert. Date
Re-Cert- Date
5. Reason for failure:
2. Repair
A.Main Line
B.Valvee
C.$ervice Line
D.Hydrants
A. Electrolysis
A.Pumps
B.Water Tower
c. Samples
D.Equipment
E.Safety
B. New construction
E. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights
4.Other
A.Line Locate
B.Inspection
C.Tap
D.Excavation
C. Poor installation
D. Other
Request for Serviceman: ~ ~c/vv~-~
7.If Me=er/Se~ice Le~: 'Cl~sify ~ ~ity:
A.Wa=er Loss ~): GPM Fire plug flushing
B.Was water Me=ered: Yes No
C.Was Customer Notified: Verbally __ ~O~R
8.If Meter Change Out:
A.Old Meter~ Reading
B.New Meters Reading.
Customer: ~
Unit
Total Gallons
vehicle/Equipment Used
Miles Hrs Equip
C.Old Meter Size/Type:
E.Type of work performed or findings:
D. New Meter Size/Type
9.If mainline or deep service repair, describe type of pipe or service line and oondition:
11.List Materials Usedz
12.If you had an accident/incident while performing thisff~request. Did you report £t? yes or no
14.Bow many tripe to do task? Slgna~ur