2001_0515 •� - • •.
WATER
Issued:5 i 5- t ( Finished: .5- 15 - Li I Employee: Grid map:
Name: Address: 1 46 n / L 7 L.
Phone Number (KM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow Insp. 2. Reeai 3. ; Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bktlow Cep 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
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 67t 2 L 6 0-1
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 Doorknocker -
VehicIe/Equipment Used
3. If Meter Change Out: Unit T Miles Hrs Equipment
q 9C I l7 Z.
A. Old. Meter # _ Readi i ' 7
B. New Meter T ,$1 . q Reading Gpc-) D�
- n
C. Old Meter Size :Type: fi t1� i OA D New Meter Size/Type S / & , 1E7L •
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
O. Ma. ^. "c_.. Crew Nte: : ::e•s. /log
11. List N1a:eriais Used:
1 If yet.: had an accident"--.::dent while performing this request. D :d you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do ask?
Signature