2001_0906 // WATER pc t, �o
Issued: 0 0 � Finished:I - 1p - Emplo Grid ma
Name: Address: 02 LR
Phone Number. (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial mete: relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date 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: ' 5 D /6 Ai 3
� e-1 err c hc",i r7u+
7. If Meter:Ser ice Leak: Classify: - City: Customer
A. Water Lou (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Caa ge Out: Unit # Miles Hrs Equipment
A. Old Meter ; ' )..rog 3 ( Reading v A213 2 0 /0 3Rd
B. New Meter # Rea
C. Old Meter SizeI Type: pi 247.57 New Meter Size/Type S /`'
E. Type of work performed or findings:
9. If mainline or deep service re -,air, describe type of pipe or service line and condition:
10. Man- hours: I R S Crew Members.
11. List MateraLs Used:
12. If you had an accident/Inc:dect while performing this request. Did you repot. it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
Signature
mCi