2001_0521 WATER
-a L — U 5',2i l
Issued: S (Finished: ( Employee: !../"/ �° /3 Grid map:
Name: Address: I1 sII e / ,c ',) e -r
Phone Number: (FD t) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackrlow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Lnsp. 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
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: Mere e “ G- -
7. If Meter,Service Leak: Classify: - City: Customer
A. Water Loss (esrmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
8. If Meter Ct:ange Out: Unit # Miles Hrs Equipment
A. Old Meter # 7 CL J Reading 0— —
B. New Meter # Reading C
C. Old Meter Size.T pe:Y ��r d►Sic D New Meter Size/Type)." / 2
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ufa: -c_.. 4 t445 Crew Me...::ers. // Li- l
11. List Mia:e .ais Used:
1?. tf ycu '.ad an accident".. while perfotrning this request. D:d you report: Yes or no
13. Water Utilities meter inspection: ,i or fail
14. How .:any Tips to do ask?
Signature