2001_0510 . • : r.•x:a +s f.,... • . y .
WATER
Issued: 5 16 Finished: S` `I ( Employee: Grid map:
Name: Address: 74i Agg 1 2 eb
Phone Number: (FD t) (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 Lzso. A. Main Line A. Pump A. Line Locate
Bk tow Cert. Dare 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 vrrt C tutted?' (9( f
7. If Meteri 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 -
Vehicle/Equipment Used
3. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter 4 Agft 9Oh3/ p e Reading¢746S
B. New Meter 4 6 7A Reading 6000
C. Old Meter Size: :Type: k¢ na<ggi rmf D New Meter Size/Type . b
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Stan - hcW3: Crew Members. Chit4t6744
11. List Materials Used:
12. If you had an accidentl:.cident white performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task? 6
Signature ,�