2001_0521 •i
WATER
Issued: — l —U Finished:
Employee: Gt�
Name:
map•
Phone Nur,.he:: IFD,t) address
(ArK):
Check for Izcuracy test: Meter Leak:
Initial mete: relocation inre: Re nons Check or-reader pressure:
d
1. $acktlow Insp.
2 . &pair 3. Maintenance 4. Other
Back:low [,-asp. A. Main Line
Bkrlo w Ctn.. Dace B. A. Pump A. Line Locate
B. Valves B. water Tower B. Line Locate
Re - Cer_ Daze C. Service Line C. Samples C. Tap p
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: 1 C rr jZ A 0 c J
7. If Meter :Se:Nice Leak: Classify: - City: Customer
1..Viter Loss (esr� ate): GP Fire plug flushing Total Gallons
B. Was Water Metered: Y es No
C A . .
. Was Custom notified: Verbally Doorknocker -
VehiclefEquipment Used
3. If Me: C ange Out: Unit T Miles Hrs Equipment
A. C d Meter 4 gj,S4 77q/ Z Reading
3. New Meter 4 25 4 y fi Reading
C. Old Meter Size.7. pe: r y iiAG s� D New Meter Size/Type
E. Type of work performed or findings:
9. If mainli-e or deep service repair, describe type of pipe or service line and condition:
O. Ufa ..:_.. Crew Me ers. lam! (/a
II. Lis: Mtyrals Csed:
A110.°11.6"11.11111