2001_0508 WATER
� Issued: Finished: .j — (_ Employee: Grid trap:
Name: Address: 7/ 3 A. h •ro rr;-
Phone Number: (l-LM) (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 Lisp. A. Main Line A. Pump A. Line Locate
Bkfiow 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 / 3 ,co r of c -7 -t-- d�►(i�i LG6t—
f,
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 � 4Miles Hrs Equipment
G it
A. Old Meter 4 _
' 7C7Ci Reading ? T3 ff.7.9Q
B. New Meter T (ny,� 7� (G Reading
C. Old Meter Size.Type: 5 /gs' 7re CiSio Y New Meter Size/Type MA91 �l
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Mari hc.:n: ! H/C5 Crew Members. t/(
11. List Materials Used:
12. If you had an accident - L cident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pas or fail
•
14. How many trips to do task?
7 � C /
Signature . ,! ?el-5(