2001_0510 WATER
Issued:.. (O. -01 Finished: S-/ o -0/ Employee: Grid map:
Name: Address: 7 3 Z AVIR) J)
Phone Number: (R M) (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 Lisp. A. Main Line A. Pump A. Line Locate
Bkrlow 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: M Ere n-- 4 O (i
7. If Meter/Service Leak: Classify: - City: Customer
A. Water Loss (esaW ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker - _
Vehicle/Equipment used
8. If Meter Change Out: Unit T Miles Hrs Equipment
A. 0,1d Meter # O 20 /S Reading /0c - 43
B. New Meter T / 2 . R;ading One!?)
C. Old Meter Size Type: • Lo. D New Meter SizeFT
E. Type of work performe s 'or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma- -c _ :. Crew Me:- :ers. dArdi F fG2?
11. List Ma::-:ais Used:
1 If you had in accident::: ::dent while performing this request. D:d you report :t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do ask?
Signature