2001_0515 WATER
issued: 5- --15 " /Finished: °°i5 °c f Employee: Grid tap:
Name: Address: c -;. q (4 Y C�1 (2 C. t a.'
Phone Number: (FN) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. packflow Insp. 2. Repair 3. Maintenance 4. Qth t
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkctlow Ce _ Dare 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: M Z e— Q
7. If MeterService Leak: Classify: - City: Customer
A. W ater Loss (estimate): 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 4 Miles Hrs Equipment
A. Old Meter 4 l` on 5 'O13 Reading ) g.3(. 2c/
B. New Meter .4 , ;2l / i / y Reading.nana
C. Old Meter Size. Type: S/ /346 D New Meter Size/ Type 4> iMMA S•/ER •
E. Type of work performed o ?findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. `Ian-hr:_.. Crew Mer..�ers. 1-1 14/2 - Lir 1305
11. List Ma:::ia!s Used:
12. If ycu ::ad an accident: while performing this request. Did you re or it? Yes or no
13. Water Utilities meter irsection: pass or fail
14. How many nips to do ask'
Signature