2001_0504 W ATER
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Issued: Finished: d Employee: IY1 C /i 44 Grid map:
Name: Address: (i). (7
Phone Number: (ICI) (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
Bkilow Cr e. 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
(p 1
Request for Services: / 45),1 41 e-1 e vr L c d G'
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 4 ) Miles Hrs Equipment
A. Old Meter # 9O.,U 'c5O Reading C C ( 1i
B. New Meter 4 4 , 1 4 . 2 , 5 - Reading
C. Old Meter Size-Type: 5/c ]'i'FCisrr ' D New Meter Size/Type S " r ►1 i- F'r
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. \ f37: - .C. . Crew NIe:-ce:s. i j
11. List Ma:e::as Used:
1 [f y eu had an accident ::.c :dent while per fcr-ning this request. :.):d you repay. it'. Yes or no
13. Water Utilities meter insrection: pass or fail
14. How many nips to do ask?
D
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