White Glove-WO 970930Grid map
Phone Number: {H~): (WK):
Time for Water lo=are ' ' ' · ~
Check for: ~cur~y~:__ M~rLa~: Ch~kw~orp~m.' ~~a~__ ~
Backflow Insp.
Re-ce.--:. Dare
Reason f~r ~a£!ure:
2. Reuair
A.Hain Line
B.Valves
C.Serv£oe Line
D.Hydran=s
A. Electrolysis
$ .MainCsnance
A.Pumps
B.WaCer Tower
C. Samples
D. EquitxnenC
E. Safety
New console=ion
List of safety equipment at site if applicable:
A.LineLocate
B.Inspec~ion
C.Tap
D.Excavation
C. Poor ins=alia=ion
D. O:her
A. Barricades 3. Cones C. Tape D. L~gh=s g:~O=her
7.If Meter/Se---zi=e Leak: Classify -
A.Waasr Loss ~.~um: G~ Fire plug flushing __
3.Was Water Hecarod: Yes No
=.Was Customer Notified: Verbally -- DOOltl~OCX~H --
S.If Mate= Change Out:
A.Old ~etar~ Readin~
3.New Meter# Reading
To=a! Gallons
Uni= # Hiles Hfs
C.Old Me=er
~.Tyg. e of work performed or findings:
D. New He=ar Size/Type
9.1~ ma£nline or deep service repair, describe c~ of pipe or se~ice line ~d condiCion~
t2.Xf you had an acci.danC/LnckdsnC while pir~o~ming Chis ricluasC. D/~ yo]~ re~ lC? yes or no
Signacu( / ' ' ~ .