2001_0504 .~ °' WATER
Issued: Finished: Employee: l//` U Grid map:
Name: Address: k> / 3 /15 k (Tor
Phone Number: (FCvt) (WK):
Check for. A :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow [nip. 2. Repair 3. Maintenance 4. Other
Backflow Lisp. A. Main Line A. Pump A. Line Locate
B1ctlow 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. C. Tape D. Lights E. Other
Request for Services: 67 /
2 ! 3 AS J C t1 i C /1 12 0 LI -i-
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 Caange Out: G unit # Miles Firs Equipment
A. Old Meter # y. 0(.3c' 0 Reading () S5/ 2 ct 3c)..-- . ??c,'
B. New Meter # :2. (G y l 5 Reading
C. Old Meter Size.Tyne: t c rJ 3 %(s -- D New Meter SizeiType rtm/95 fey - /<
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 'C- .. 1 Crew Mem. :ers. (mot - I/
11. List `•1a:::iais Used:
12. If you ad an accident:. :dent while perfcrring this request. D :d you repar. it? Yes or no
13. Water Utilities meter inspection: or fail
14. How r aiv nips to do :ask?
1 ‘;_
Signature I , � .