2001_0515 (2) WATER
Issued: S =I S - -0 t Finished: S-15 -r} 1 Employee: Grid map:
Name: Address: ( t t l, L i F tl1 e Lā q
Phone Number (FDA) (WK):
Check for. :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. B ackflow Insp. 2. Repair 3. Maintenance 4. Qib
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow 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: / AC rcr2
7. If Meter.Service Leak: Classify: - City: Customer
A. W ater Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehicletEquipment Used
3. If Meter Change Out: Unit T Miles Firs Equipment
A. Old Meter 4 c? '7 Reading O i l $'
B. New Meter ā¢ Reading CaC cD0
C. Old Meter Siz .T; pe: / 0 t J q r4 D New Meter SizelType S /, 1JAS -
E. Type of work performed Yr findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man--: _ :. Crew Mershers. ( f /1ā{t / i if ROB
11. List Ma:er:ais Cased: I/ ,
13. If you had as accident :::::dent while performing this request. Did you repot.: it? Yes or no
13. Water (: nlities meter iespection: pass or fail
14. How .:any trips to do ask?
Signature