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2001_0510 WATER Issued: -1 n - O j Finished ?h- 1 O (Employee: Grid map: Name: Address: 21 y J�3 A lei Y Phone Number. (ICI) (WK): Check for. Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspections Re -read 1. Backflow Insp. 2. Repair 3. Maintenance 4. Other Backflow Insp. A. Main Line A. Pump A. Line Locate B'<flow 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: , 6 D Z JT' 7. If MeteriService Leak: Classify: - City: Customer A. Water Loss (esrrate): GPM Fire plug flushing Total Gallons B. Was Water Metered: Yes No C. Was Customer Notified: Verbally Doorknocker - Vehicle/Equipment used 8. If Mete: Change Out: Unit 4 Miles Hrs Equipment A. Old Meter # c ! L7 (03 13 Reading . z ' B. New Meter -51 as q9 Reading (51:3 ©27 C. Old Meter SizeType: / 1VIA< `7E72 D New Meter Size/Type S/ IVIA 'rek, E. Type of work perormed or findings: 9. If mainline or deep service repair, describe type of pipe or service line and condition O. Mar 'C_... Crew Me -cers. ' � + 11. List Nla: :-:ais Used: 1?. If ycL: had an accidenc::. ::dent while perfuming this request. D:d you report it? Yes or no 13. Water Utilities meter iestection: pass or fail 14. How .:.3.1y trips to do ask.? Signature •