2001_0517 WATER
Issued:-- l '1 O ( Finished: S-1 1-0/ Employee: Grid map:
Name: Address: yet E f 71 Z
Phone Number: (KM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backrlow Insp. 2. Repair 3. Maintenance 4. Other
Backlog• Insp. A. Main Line A. Pump A. Line Locate
Bkrlo x• Ce 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: M. ere f 4 C5 cj
7. If Me:en Service Leak: Classify: - City: Customer
A. Water Lou (esc:.^ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehic1eEquipment Used
3. If Mee Caange Out: lint 4 Miles Hrs Equipment
A. Old Meter 4 R0g /s34 Reading 3 O
3. New Meter ...2ff (SS4 Reading 000()
C. Old Meter Size ;Tee . P'RQ.P i <in).l D New Meter Size/Type f ) 44 7-t L
E. Type of work performed or findings:
9. If mai lire or deep service repair, describe type of pipe or service line and condition
10. Ufa- ..:_.. Crew NIe - :ers.
11. Lis: Mi:e':ais Used:
12. If nist an accide :r::.: :dent while perfcr:ning this request. D:d you :ever: a' Yes or no
13. Water Utilities meter irsrection: pass or fail
14. How many trips to do ask?
Sienatur_