2001_0504 WATER
Issued: Finished: `i' Employee: 1 cJii'ei Grid map:
Name: Address: bq S h
Phone Number: (FBI) (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
Bktlow 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 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: (�r) a `1 I s `i 'c7 r ci /)'1f' ,- 0 h (& Js-e
7. If MeteriService Leak: Classify: - City: Customer
A. W ater Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Vii as Customer Notified: Verbally Doorknocker Vehicle/Equipment used
3. If Mere: Change Out: Unit 4 Miles His Equipment
A. Old Meter # C I()9.U ( /L/ Reading / C 2 Cf 30 '()
B. New Meter T `2, (e y 5 / (4 Reading Or
C. Old Meter Size.Ty e: 5/9 J '-' c, Sl Cs) D New Meter Size/ Type 5 /h' !f/ it
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ufa :..__ :. I SIRS Crew NIe... :ers. (.•{ //
11. List Materials Used:
12. [f • 'ad an accidenCL.::dent while performing this request. D:d you repent . :' Yes or no
13. Water Utilities meter inspection: (pup or fail
14. How .:any trips to do :ask' �/
Signature ' 0 (.1 7 / — ek11