2001_0426 WATER
Issued: Finished: L/ - L - Of Employee: 71/1 G(1 Grid map:
Name: Address: / p lEr ► c .
Phone Number: (HM) (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
Below Ctn. 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: e. r h (1.11 E (fl y
7. If Meten'Service Leak: Classify: - City: Customer
1. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment Used
3. [f Meer Caange Out: Unit; Miles Hrs Equipment
A. Old Meter `6 Reading C '. ) ,Cy 2 q
B. New Meter . .16 I- I1 � C' Reading
C. Old Meter Size-Type: 5/6 D New Meter SizeiType `({ /'r/ -ko,r
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man 1 t-(E Crew Members. (j` ti
11. List N(a:er:als Used:
12. [f you bad ah accide nG .:. ::dent while performing this request. Did you repar. it? Yes or no
13. Water Utilities meter inspection: or fail
14. How .:.nay trips to do ask?
Signature )4t A/(1,4.-„.1