2001_0516 WATER
Issued:5- (6" 0 !Finished: red (Employee: Grid map:
Name: Address: 1 Co G, E - (3 FT{--/ P L
Phone Number: (ivt) (WIC):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. }ttpair 3. Maintenance 4. Other
Backlow asp. A. Main Line A. Pump A. Line Locate
Bkt10 x• Crr Dace 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: (Y( e 7eX A D t r
7. If Meter. Service Leak: Classify: - City: Customer
A. W ater Loss (escalate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Nie :e: C ange Out: L'nit 4 Miles Hrs Equipment
A. Old Meter # 9v (:).6104 Reading /3 /JO
3. New Meter # 0 y 30 Reading 00000
C. Old Meter Size-Tyne: >'- e cte,u D New Meter Size/Type � _
E. Type of work performed or findings:
9. If mai: li: a or deep service repair, describe type of pipe or service line and condition:
10. Ufa: -:_.. Crew Me:-::e :s. e s
11. Lis: Ma:e als Used:
P. If , :L ha.: an accide n: _..:dent while per this request. D:d you .erer.. Yes or no
13. Water Utilities meter inspection: pass or fail
14. How :—nany rips to do ask'
Signature