2001_0510 •
WATER
Issued: 5., t o -L j Finished: S /h —C1 Employee: Grid tap:
Name: Address: -2/ 4 / 2- -CLOY
Phone Number. (HM) (WK)
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackrlow Insp. 2. Repair 3. Maintenance 4. Om
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkrlow 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: ivtcre Z Q 607
7. If MeteriService Leak: Classify: - City: Customer
A. Water Loss (esrmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorimocker -
Vehicle/Equipment Used
3. If Me:: Change Out: Unit 4 Miles Hrs Equipment
A. Old Meter 4 Reading e_gg'6,
B. New Meter 4 . Reading el) c"(7
C. Old Meter Size-Type: PPecisr d,,t/ D New Meter SizerType 5 ftrA -S 7 TA •
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:;
•
i•). `1a- .c Crew Me'�ers. a
11. List Mate::ais Used:
12. If you ^ad an accident ::.c:dent while performing this request. D :d you reper :t' Yes or no
13. Water Utilities meter inspection: pass or / fail
14. How many yipstodotask?
Signature
3K .