2001_0515 WATER
Issued: < 1<- i Finished: 5 —IS- t: 7 j Employee: Grid tap:
Name: Address: A& iL
Phone Number (IN) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. $R,k 3. Maintenance 4. Qsbq
Backflow Lup. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower . B. Line Locate
Re -Cer_ 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: - A • "' 4 ') •
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Lou (esrmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
3. If Mere: Change Out: Unit Miles Hrs Equipment
A. Cd Meter # 1'0 Reading (1S
B. New Meter T 4 /3 j Reading
C. Old Meter Size ': 54 Q.2ti -ic 104 D New Meter Size/Type
E. Type of work performed 61 findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. NIa: -c_.. Crew Mere. e s. (1w.1, mi
11. List h: r ais Used: /
12. If you had as accident"--.::dent while performing this request. D:d you report :t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do :ask?
Signature