2001_0515 WATER
Issued: $ - S a Finished: S -- IS —41 1 Employee: Grid map: n
Name: Address: y (e ��' 771-67-- W 6
.
Phone Number (HM) (WK)
Check for a ::ur3cy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow Insp. 2. Reoair 3. Maintenance 4. Other
Backflow Lisp. A. Main Line A. Pump A. Line Locate
Blcflow Cep 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: - — A 0 (.77
7. If MeteriService Leak: Classify: - City: Customer
A. Water Loss (estmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Meter Caange Out: Unit 4 Miles Hrs Equipment
A. Old Meter 4 90 c1 J ') 15 Reading h 3 S
B. New Meter 4 d tp / .Readin g oc6E)i )
C. Old Meter Size.Type: aveAz<rn o,! D New Meter Size/Type 5- N l/if"702,
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Mad-hr.: Crew MIe:::.ers. f.Zi % �C1
11. List Nta: --:ais Used:
12. If yeas ^ad 1.: accident ...c :dent while performing this request. D :d you re or :t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How .:sty nips to do ask?
Signature