2001_0517 •
WATER
Issued: S -1 I Finished: S - 17-0 1 Employee: Grid map:
Name: Address: ,2 (AI E.
Phone Nur:.cer: (KM) (WK):
Check for Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation jasper-dons Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Backlow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dare 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: M 6 7 IQ- d O (J7
7. If Meter:Service Leak: Classify: - City: Customer
A. Water Loss (estiW ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If M.::: Change Out: Unit 4 Miles Hrs Equipment
A. Old Meter 4 005,:f& f' Reading b2.3 g7
3. New Meter .4 aa7/. 3 Reading boob
C. Old Meter Size.Ty e: g' P1ZU iS (OA D New Meter Size/Type ( - S 7 e 2
E. Type of work performed or findings:
9. If rr.air.lize or deep service repair, describe type of pipe or service line and condition:
10. Crew
11. Lis: Ma:e his Used: /
12. If ; Cc had a: ac:ide tt :-.::dent while performing this request. D r you re per. :t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do ask?
Sienature