2000_0426 WATER
Issued: Finished: Ne'vec Employee: / 7Y'l''d Grid map:
Name: Address: f SI 2 E 1 (' 1
Phone Number (KM) (WIC):
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
Bkrlow Cert. 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: 47e r (tic, c ___ C €-1--
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehicleEquipment used
3. If Meier Ceange Out: Unit T Miles Hrs Equipment
A. Old Meter* C' 9'6 5(03:2- Reading j S / 2T3
B. New Meter . .2. (obi 13 2.E Reading
C. Old Meter Size.Type: irpp$tovJ D New Meter SizerType . >4 Az,f_s:/
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma: ..c _.. l ; Crew Members. - (/
11. List Ma:e:ials Used:
13. If you :,ad az accident while performing this request. Did you r per :t? Yes or no
13. Water Utilities meter inspection: ass ) or fail
14. How ,:any nips to do ask? / •,
Signature 7ti /,