2001_0516 WATER
Issued: S -1(o -O 1 Finished: 5- 16 -O ( Employee: Grid map:
Name: Address: qi3 5. G EL-TtJArE
Phone Number (FCvf) (WK)
Check for. A :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inscections Re -read
1. $ackflow Inso. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Below Ctn. 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
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: OGLE r& i2. a O
7. If MeteriService 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 -
VehicletEquiptnent used
3. If Mere: Caange Out: Unit # Miles Hrs Equipment
A. Od Meter # ag1 Reading CD7k
B. New Meter # Acq (oS(d9 Reading &Don
C. Old Meter SizeT;pe: 1 p Al IA z D New Meter Size/Type N�1
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. eta: "C-... Crew Me:: :c s.
11. List Ma : :: Used:
12. If you had an accident—..:::dent while performing this request. D :d you repor: :t? Yes or no
13. Water Utilities meter irs fection: pass or fail
14. How .ra.iy trips to do ask?
Signature