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2001_0516 WATER Issued:,s -1(0'0 /Finished: ,$ —! (a -O/ Employee: Grid map: Name: Address: / 15-4 E- RE'T/-/ E4_, Phone Number: (FBI) (WK): Check for: Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspections Re -read 1. Backflow Insp. 2. Repair 3. Maintenance 4. Other Backflow Insp. A. Main Line A. Pump A. Line Locate Bki low Cert. Date B. Valves B. Water Tower . B. Line Locate Re 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: /Wer 1 © ( 7. If Meter, Service Leak: Classify: - City: Customer A. Water Loss (estimate): GPM Fire plug flushing Total Gallons B. Wu Water Metered: Yes No C. Was Customer Notified: Verbally Doorknocker - VehiclerEquipment Used 3. If Meter Caange Out: Unit 4 Miles Hrs Equipment A. Old Meter 4 ''/ O d 6 4-9S Reading /$57, B. New Meter T oL( ?C Reading ,CE C. Old Meter Size.Ty e: avow() D New Meter Size/Type .- t t 1t E. Type of work performed or findings: 9. If mainline or deep service repair, describe type of pipe or service line and condition 10. Nfa : -c_ :. Crew Me:-.ers. 11. List Ma:triais Used: 1?. If you had a : accident ".. while performing this request. D :d you report :t? Yes or no 13. Water Utilities meter insrection: pass or fail 14. How ,;.any trips to do :ask? Signature