2001_0515 •
WATER
Issued: 5-1 g - r i Finished: s _, s .-e-; i Employee: Grid map:
Name: Address: til i3 r/,te
Phone Number: (FCvt) (WIC)
Check for. :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow Insp. 2. &mak 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow C: - Dare 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
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: ,Te 1- 4 11 i
7. If Meter:Service 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 Doorkttock :r -
Vehicle/Equipment used
3. If Me : :: Change Out: Unit # Miles Hrs Equipment
A. Old Meter # go 5,q 7 0 Reading ( 76, ( I/
B. New Meter ' , 2 6 4 / 4 07 Reading f t)v
C. Old Meter SizeT;•pe:. t344- D New Meter Size/Type SI Poi-A5
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man--c._::: Crew Nf:-:ers.��.' 1, Bab'
11. List Ma::=ais Used:
13. If ycu had an accident ::. =:dent while performing this request. D:d you report :t? Yes or no
13. Water Utilities meter irstection: pus or fail
14. How many nips to do ask?
Signature