2001_0517 .� -
WATER
Issued: S 1-7 0 1 Finished: 5 -1 l- 0 I Employee: Grid map:
Name: Address: 1 7 0 6 Bel HE L_
Phone Number: (HM) (WK):
Check tor. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation ins;.ecrions Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Backlow Insp. A. Main Line A. Pump A. Line Locate
Bkrlow Cr.. : Date B. Valves B. Water Tower . B. Line Locate
Re -Cerc Dace 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: ME CL „. (Do
7. If Meter; Service Leak: Classify: - City: Customer
A. Water Loss (esrY ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehicluTquipment used
3. If Me ::: Caange Out: Unit 4 Miles Hrs Equipment
A. Old Meter* Q 0 r'1 I Reading a.) qQ-
3. New Meter 4 01 I .( �j Reading 6OC O O
C. Old Meter SizeTyne: /tr F' iQDoiS[Dit.1 D New Meter SizeiType A. S`'
E. Type of work performed or findings:
9. If mainli a or deep service repair, describe type of pipe or service line and condition:
10. `fa- `.c_.. Crew Me:::e s. ( . .�i mt...h.t & //3OJ
11. Lis: Nfa: :::ais Used:
1?. [f ; cc: =ad a t lcadent::.::dent while performing this request. 2,:d you re cr: f Yes or no
13. Water Utilities meter insrection: pass or fail
14. How many nips to do ask'
Siznatur_