Town Center West-WO010529Issued:~5 ' ,~Q' O I Finished:
Name: ~'~ O3~ ~
Phone Number: (~lqM) (J (,/
WATER
Employee: ~ ~ . ~Gfid map: ,.~
Address: 'To~
17-
Check for: Accuracy test: Meter Leak:
Initial meter relocation inspections
Check water pressure:
Re-read
1. Backflow Insu.
2. Repair 3. Maintenance
4. Other
Backflow Insp.
Bkflow Cert. Date
Re-Cert. Date
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. Equ~ment D Excavation
E. Safe~y
5. Reason for failure: A. Electxolysis B. New Constxuction 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: ~ e.~<~
7. If Meter/Service Leak: Classify: - City:
Customer
A. Water Loss (estimate): GPM __
B. Was Water Metered: Yes
C. Was Customer Notified: Verbally
Fire plug flushing. Total Gallons
No
Doorknocker -
8. If Meter Change Out:
Vehicle/Equipment Used
Unit # Miles I-Irs Equipment
A. Old Meter # Reading
B. New Meter # Reading
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 condition:
10. Man-hours:
11. List Materials Used:
Crew Members.
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many txips to do task?
Sisnature