Windsor Estates-WO020801 I
Issued: ~! ! Finished:
Nam,:
Phone Numar (~):
Check For: Accuracy Test
~itial Meter Rel~ation ~s~ctions
1. Backflow Insn.
Backflow Insp.
Bkflow Cert. Date
Re-Cert. Date
WATER
Employee:
Address:
(WK):
Meter Leak
Grid Map:
Check WaterPressure
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: ~'~{" ~q~ f (~'°o'-02
7. If Meter / Service Leak, Classify: City
A. Water Loss (estimate): OPM Fire Plug Flushing
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBAI.LY
Customer
Total Gallons
DOORKNOCKER
Reading
Reading
New Meter Size / Type
8. If Meter Change Out:
A. Old Meter #
B. New Meter #
C. Old Meter Size / Type
E. Type of work performed or findings:
/ ~.Y~'~
9. If mainline or deep service repair, describe tT~ of pipe,6r service line and condition:
lO. Man hours:
11. List materials used:
Crew members:
12. If you had an accident/incident while performing this request, did you report it?
13. Water Utilities meter inspection: PASS or FAlL
14. How many trips to do task?
YES
Signature
or NO