2001_0516 .»
•
W Al
Issued: s._
Finished:
_5z/6 .n/ employee: Grid map: _.-----
Name:
Phone Numcer: {I�Q Address: _200 a S , i Tltir� E
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections
Re -read
1. $ackilow last'.
2. Emir 3. Maintenance 4. Other
Backflow Lnsp. A. Main Line
Below Cep Date A. Pump A. Line Locate
B. Valves B. Water Tower . B. Line Locate
Re - Cert. Date 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:
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker
3. If Meter C ange Out:
Vehicle/Equipment used
Unit ;Miles Hrs Equipment
A. Ord Meter to 5 Cold Reading / Z U1 c
B. New Meter .4 • _5g L Reading or)() ()
C. Old Meter Size.Type: /.�.{., - -n 1 k, D New Meter SizeiType t -c-j
E. Type of work performed or findings: t '
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Nfan -`c_:: Crew Me:n ( (97 B
11. List `•tattr:ais Used:
12. if you had a.: accident:.:: :dent while perfuming this request. D :d you report :c? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How ,r.a..w trips to do ask?
Signature