2001_0510 •
WATER
Issued: S'" to ' Finished: .S^ 1 d O 1 Employee: Grid map:
Name: Address: Z.(C7 6 P C t Ace
Phone Number: (HM) (WK):
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackilow Insp, 2. Repair 3. Maintenance 4. Om
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
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: 4 7'E R. ,Ll tyT
7. If Meter/Service Leak: Classify: - City: Customer
A. Water Loss (esn ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehicleiEquipment Used
3. If Meter Change Out: Unit T Miles Hrs Equipment
A. O d Meter # q671 ?i 77 Reading
B. New Meter _ y�'jf j Reading iw) )
C. Old Meter Size.T;pe: �" _ to. D New Meter Size/Type MAST -Ee.. -
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ufa _.. Crew Me:-:ers. (44,11 E flag
11. List N13:e7iais Used:
12. if y ci: ad an accide nt :.: :dent while performing this request. Did you re ;cr :t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do :ask?
Signature