2001_0515 WATER
Issued: i t S -- F2 t Finished: __ -01 Employee: Grid map:
Name: Address: g.44 f e .4 Y ( l + .C—L
Phone Number (FDA) (WK)
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Reflair 3. Maintenance 4. Other
Backflow Lisp. A. Main Line A. Pump " A. Line Locate
Bktlow Cert. Date 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
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: M f.1& R-- A 0 't`
7. If Meter,'Service Leak: Classify: - City: Customer
A. W ater Loss (esrrr ate): 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 1® $ 6 Reading/O/ L
B. New Meter T Reading (1 ti cDC) _
C. Old Meter Size.Type: i P et 1 5i r%as. j D New Meter SizeiType S,/ �' S W .
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 Merr. e:s. ell 41 of /.moo
11. List Marc =ais Used: S/
12. If you had an iccident::.c:dent while performing this request. D :d you repar: it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How .rxiy nips to do :ask?
Signature