Windsor Estates-WO020815 WATER
Issued: ~1 [~[~ Finished: Employee: ~'~///Ih ~ Grid Map:
Phone Number (I-LM): r2J L~ - 6~- I ] O,~ (WK): __
Check For:
1. Backflow lnsp.
Backflow Insp.
Bkflow Cert. Date
Re-Cert. Date
Accuracy Test
Meter Leak
Check Water Pressure
Initial Meter Relocation Inspections Re-Read
2. Repair 3. Maintenance 4. Other
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. Equipment D. Excavation
E. Safety
5. Reason for Failure: A. Electrolysis B. New Construction 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: '~¥ r~ I 0r , F-
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7. If Meter / Service ~ak, Classify: City
A. Water Loss (esti~te): GPM ~ Fire Plug ~ushing
B. Was Water Metered: ~S NO
C. Was Customer Notified: ~AI.I.Y
Customer
Total Gallons
If Meter Change Out:
A, Old Meter #
B. New Meter #
C. Old Meter Size / Type
E.
DOORKNOCKER
Reading
Reading
New IVIeter Size / Type
Type of work performed or findings: 7ge,,~ vf/~ ~//,,~e 7'a ,~/'JV,~ .~/~ ,~'-~///~"
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:
14. How many trips to do task?
PASS or FAIL
Signature