Town Center West-CS020411Phone
Check For: A¢cuzaey Tes~,
Initial Me~r Relocation Insp~ons
Bkflow Cert. Date
Re-C~rt. Date
A- Mah~ Line
B. Valves
C. Service Line
D. Hydran~
Reason for Failure: A. Electrolyxis
Check Water Pre,ssu~
R~-Read
A. Putup
B. Wa~r Tower
C. Sampl~
D. Equipment
E. Safety :'
B. New Conslruc~ion C. Poor Inslallslion
A. Line Lo,ate
B. Line Locate
C. Tap
D. Excavation
6, List of Safegt Equipment at Sit~ ('ff applicabk):
A. Barricades B. Con~s C. Tape D. Lights E. Otter
I~QUI~ST FOR SERVICES: ~l[~-ul~
4-tt--oz
7. If Meter/Service Leak, Classify: City
A. Water Loas (eqimate): GPM ~ Fire Plug Flushing,
B. Was Wa~r M~ter~i: YF~ NO
C. Was Customer Notified: 1/'P..RBAT.Ty
8. IfMeterChange Out:
A. Old Meter #
B. New Meter #
C. Old Meter Size / Type
E. Type ofworkperformed or findings:
10. Man hours:
Total Gallons
DOORKNOCKF.,R
Reading
Reading
New Met~' Size / Type
mainline or deep serv/ce repak, describe type of pipe or serv/ce line and condition:
Crew mem~rs:
I t. List materials used:
t 2. If you had an accidem/incident while performing ~.is request, did you report it?
t3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Y'ES or NO
Sis~ature