2001_0504 WATER
ot
Issued: Finished: Employee: iY1C-if r' 6' Grid map:
Name: Address: 0 tq, / '" �`/
Phone Number: (IDl) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backilow Inky. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkilow Cen 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
S. 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: £ 0 ti -1"U i'' A j'1'1 e 1r C: h c) Ll
7. If Meter,Service Leak: Classify: - City: Customer
A. Water Loss (esdr ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
3. If Me :er C:ange Out: Unit 4 Miles Hrs Equipment
A. C d Meter 4 Cie ).CV ..Z 2. Reading 3 0;4.1 2 , 30 �0
B. New Meter 4 '2. 1 5 (. Reading
C. Old Meter Size.T;pe: ,jf free i5 e.4 n. D New Meter Size/ Type 3/g 14,¢s: f
E. Type of work performed or Endings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. `13- ..__ :. f Crew Mem :,ers. 1 f
11. List M3:eriais Used:
12. [f y :c ad an accident::.: :dent while perfcrming this request. D:d you repent' Yes or no
13. eater Utilities meter inspection: p or fail
14. How .:any trips to do ask'
Signature J fite/i-C3.1/