2001_0510 WATER
Issued: Finished: Employee: Grid map:
Name: S-- i'D 'O ( Address: 73 M I) Fr) !Zh
Phone Numcer: (HM) (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
Bktlow Cert. Date B. Valves B. Water Tower . B. Line Locate
Re -Ce:_ 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: /4 t TIC f J ( C�
7. If Meter Service Leak: Classify: - City: Customer
A. Water Loss (escsate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle!Equipment used
3. If Me :er Caange Out: Unit; Miles Hrs Equipment
A. Old Meter O 9 5 [ ) 1 7 Reading fiCgcji
B. New Meter T ,26 4 r) , Reading fe
C. Old Meter SizaT;pe ? IC C „ Ark New Meter Size/Type $ . )4-YT )
E. Type of work performed s findings:
9. If mainline or deep service repair, describe type of'pipe or service line and condition:
10. Ma- -c_.. Crew �[e -xis. ! - C d
11. List Ma :erais Used:
12. If yca ::ad an accident::. ::dent while performing this request. D :d you repor.:t' Yes or no
13. Water Utilities meter inspection: pass or fail
13. How ,:.any trips to do ask'.
Signature