2001_0508 WATER
Issued: Finished: "5 `(3 - D Employee /�;:z� L Grid map: I
Name: Address: '7c. `l i+ ) 1-C? V C(
Phone Number: (I (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 [nsp. A. Main Line A. Pump A. Line Locate
Bktlow Cert. 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: 7< j 1 'S h c-e. n'1 £ f�C e i� gi_ro
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 # Miles Hrs Equipment
A. Old Meter 4 1.5 ( Reading G r5
B. New Meter 2 lG y� J � � Reading /
C. Old Meter Size.Type: 1r to 1 at. D New Meter SizefType 3 /( 014-141--qtr
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
:0. Man- hc:s: ! U •` ) Crew Members. ti, / (
11. List Materials Used:
12. If you had an accident incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: as or fail
•
14. How many trips to do task?
Signature i r r %�;