2001_0515 WATER
Issued: 4 1 Finished: S w 1 S — c ( Employee: Grid map:
Name: Address: 33 J Ace' tf t G o
Phone Number (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter 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: Men= 12. A Q f fT
7. If Meter /Service Leak: Classify: - City: Customer
A. Water Loss (esrzv ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
• C. Was Customer Notified: Verbally Doorknocker
Vehicle/Equipment used
3. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter #0 S E<a L Reading
B. New Meter T �.(.yy r3)(f Reading C�
C. Old Meter Size.Type: si 15 A(,.*; ? D New Meter Size/Type Si:, Ivi,4,5-r-r AL •
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition
10. Man--c.::: Crew Mle...cers. e1, po
11. List Nta:e::ais Lased:
12. If you had in accident: :dent while perforning this request. Dad you reror it? Yes or no
13. Water Utilities meter inspection: pus or fail
14. How . :any hips to do ask'
Signature