2001_0516 WATER
Issued: 5-16-0 I Finished: S - 1 6- '0 ( Employee: Grid trap:
Name: Address: 1 ,.sue -
Phone Number (1-LM) (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
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: 1` , ` z 4. b c/
7. If Meter,:Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Meter Change Out: Unit 4 Miles Hrs Equipment
A. Old Meter 4 R OS E'.e Pi Reading /gsjq Z
B. New Meter T D / 3 f{ Reading 0000
C. Old Meter Size.Ty e: � PQee. sic og D New Meter Size/Type 1-
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: nc _.. Crew Mer::.:ers.
11. List N :er:als Used:
13. If you had an accident :.::dent while performing this request. Did you report :t? Y_s or no
13. Water Utilities meter inspection: pass or fail
14. How .:any nips to do ask?
Signature