Waterside E P3-WO 970930WATER --
Address:
_ Grid map
Phone Number:
Check for: ~y ~:__
Backflow Insp.
Bkflow Cea.Date
Re-Cert. Date
5. Reason fg= failure:
2. Repair
A.Main Line
B.Valves
C.Service Line
D.Hydrants
A.~umps
B.wa=er Tower
C.Samples
D.Equipment
g. Safety
A. Electrolysis B. New cons=---uction
Lis= of safety equipmen= at site if applicable:
4.O~her
A.Line Locate
B.Inspe~ion
C.Tap
D.Excavation
C. Poor instal!etlon
D. Other
A. ~arricades 9. Con~ Cl Tape D. Lights ,E. Other
Reques=
for
0
?.If Meter/Se.--;ice Leak: Classify - ri=y:
A.Wa:er Loss ~-~-~m~: GPM Fire plug flushing__
B.Was Wa=er Metered: Yes No
=.Was Customer No:iliad: Verbally __ DO~P2~ --
To=al Gallons
S.If Me=er Change 0u::
A.Old Me=erS Readin~
~.New Me=erS. Reading
vehicle/E~uip~en= Used
Unit $ Miles Hfs
C.Old Meter Si:e/Type:
E.Type of work performed or findings:
D. New Meter Size/Type
9.If mainline or deep service repair, describe tyl~e of pipe or service line and condition:
10.Manhours: Crew
ll.List Materials Us~:
12.If you had an accident/incident whale perfo~.'ming this request. Did you.re~o~t? yea or so
~4.aow many trips to dc ~ask~ _~/'~-//x~W/~~