2001_0510 WATER
Issued: 5/ Jd { O / Finished: 5 /io Is/ Employee: Grid map:
Name: Address: 'I / s 1 �arJ
Phone Number: (IN) (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 L-tso. A. Main Line A. Pump A. Line Locate
Bk.low Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent_ 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 .Cpnee C. Tape D. Lights E. Other
Request for Services: 8'6 9 ill &' (; hi vt'1
7. If MeteriService 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
8. If Meter Change Out: / Unit 4 Miles Hrs Equipment
A. Old Meter 4 c(01/5 7 C Reading
B. New Meter 4 2f 4,2 -77c Reading
C. Old Meter Size Type: PEI ac tad - D New Meter Size/Type )445TeZ
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
tick5 14
10. N1an- ac',:: s: I Crew Members. t ( t/' /
11. List Ma :eriais Used:
12. If you had an a ccidentL.cident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do task?
Signature