2001_0510 • . : y . _ . t_ •
WATER
Issued: S /o d 1 Finished: 7 /P // Employee: Grid map:
Name: Address: N 4511 22
Phone Number: (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
Bk.tlow Cer*_ Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Ex:avation
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:
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 -
VehiclelEquipment used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # O D s .1 Reading olio io Y
B. New Meter # LIo I" Reading 0000
C. Old Meter Size:Type: l //346 1t D New Meter Sizefrype $ 1544S7 R.
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
l0 . Man -hours: Crew Members. G!' 4 " K �'� - ''�
11. List Materials Used:
12. If you had as accidentL.cident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
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14. How many trips to do task?
Signature