2001_0510 WATER
issued: S I o o f Finished: C ( O-01Employee: Grid map:
Name: Address: -2.1 g 8
Phone Number: (KM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Dackrlow Insp. 2. Repair 3. Maintenance 4. Q
Backflow Lisp. A. Main Line A. Pump • A. Line Locate
Bkflow Cep. Date B. Valves B. Water Tower . B. Line Locate
Re -Cep_ 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:
k Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: `14P 7D • \ ()
7. If MeterService Leak: Classify: - City: Customer
A. Water Loss (estate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equiptnent Used
3. If Meter Change Out: Unit # Miles Fin Equipment
A. Old Meter # q 0 6,31 1 Reading // Zq
B. New Meter # 40. /2 /Reading :O aO(
C. Old Meter Size.':ype: • 'o D New Meter Size/ Type rraS rz fL •
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma-c.:. Crew M[e' :e:s. ���h ✓k'•[ia4G /8d1
11. List N[a:eriais Used:
1 If you had an accident::.: :dent while performing this request. D :d you report it? Yes or no
13. Water Utilities meter inspection: pus or fail
14. How ,;.any zips to do ask?
Signature