2001_0426 WATER
Issued: Finished: 1 .(c - (;l Employee: /W / , Grid map:
Name: Address: i ij g AS {1 e r
Phone Nurn'cer: (I-Lv!) (WK):
Check for:A:curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow L-up. A. Main Line A. Pump A. Line Locate
Bkftow 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: /116i C 11 0, tu'Clugi 064 4-
cl
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 -
VehiclelEquipment Used
3. If Meter Caange Out: unit # Miles Hrs Equipment
A. Old Meter # 817$ Reading'0 2 700: 9G
B. New Meter # ti !''S 9- 4 Reading 7
C. Old Meter Size-Type: Trec icu, ✓ k D New Meter Size/Type/714_54e( Vi?
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 : -__ :. l �' ' Crew Mern ers. Lf - /7
11. List Ma:triais Used:
12. [f you ^ad 1 t accident,::-.::dent while performing this request. Did you report it? Yes or no
O. Water Utilities meter irsrection: or fail
14. How many trips to do ask?
s ignature e c "-t�