2001_0515 WATER
Lssued: ,5'. °1S' i Finished: 5 s i - Employee: Grid tap:
Name: Address: 1) 44 t- C.1'f La, e,0 /
Phone Number: (I M) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow Insp. 2. Repair 3. ; Maintenance 4. Om
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cep 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
S. 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: er6 A 0 UT" i
7. If MeteriService Leak: Classify: - City: Customer
A. Water Loss (esdrr ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclaFquipment Used
3. If Mete: Caange Out: Unit Miles Hrs Equipment
A. Ord Meter 4 drlcgjc / Reading r .� .
B. New Meter .4A,(dj Reading *] ]
•
C. Old Meter Size .Type: 5' R,&. -67Z, D New Meter Size/Type 5-1 Merrer,
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma- 'c-. :. Crew Mer "e :s L a
1l. List Nfa:e=ais Used:
12. If you had an accident ::.::dent while performing this request. Did you report :t? Yes or no
13. Water Utilities meter itscction: pass or fail
14. How .mazy trips to do 'ask?
Signature