2001_0508 WATER f
Issued: Finished -.. Employee: /3'l � IL Grid map:
Name: Address: 7 4 r
Phone Number: (1-N) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Backfloo.v Insp. A. Main Line A. Pump A. Line Locate
Bki low 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
/ ricades B. Cones C. Tape D. Lights E. Other f�
Request for Services: 7192. /�' 0 r - �1' / 1 f'7 I� haw a C� w ( a
7. If Meter /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 -
VehiclelEquipment Used
3. If Meter Change Out: Unit 4 Miles Hrs Equipment
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A. Old Meter Q a f , 2 Reading ��-- ! G �
B. New Meter # (f' �/ 2 712 Reading
C. Old Meter Size/Type: 57i? )e fi2 i S c ma D New Meter Size/Type -`'Y3 /17/9.:12_
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 -he W s:
J Crew Members. •i Cl
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: �� or fail
•
14. How many trips to do task?
Signature
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