2001_0504 • •
WATER
Issued: Finished: ) Employee: /V/ Grid map:
Name: Address: (0 A )1 Cc ✓'c
Phone Number: (I-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 Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cep Date B. Valves B. Water Tower _ B. Line Locate
Re-Cer_ 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: f 1 /151-1 .c fViQ e ci., .tl{ e U u +'
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 -
VehicleEquipment used
3. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # c10.5` Reading / 2.7 )O 2,q0
B. New Meter T (- y at t 1 Reading C
C. Old Meter SizeT.pe: 5/C! D New Meter SizeiType 5/ M f )1
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma ..__:::: J r Crew Men::e:s. 4 ` /1
11. List Materials Used:
12. [f you ::ad is accident :::c:dent while performing this request. you reper: a° Yes or no
13. Water Utilities meter inspection: 'pass or fail
C-
14. How many trips to do ask?
Signature .