2001_0504 •
WATER
Issued: Finished:.E'' Y t Employee: ge6C( Grid map:
Name: Address: 60 1 5 )1 T' ff�
c r
Phone Number: (I-LM) (WK):
Check for: A:curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re - read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Lrtsp. A. Main Line A. Pump A. Line Locate
Bkrlow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cer:. Daze 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: 111 e -f "tom c `1 Gl l� e o Le-f
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 -
Vehicle/Equipment used
3. If Meter Caange Out: unit 4 Miles Hrs Equipment
A. Old Meter 4 9V' (P 1 . ) � Reading O . 1() 0 / 2C - -Z f 1
B. New Meter 4 Z-la L{'}..- r a a.J- Reading •
C. Old Meter Size -Type: 5/F FiZe Sax) D New Meter SizeiType 5/i
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 - / Nr5 Crew Nfe,_.:ers. 1/ • i(
11. List Ma:e iais Used:
13. [f you ::a::: an accident,'- ::dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: ) or fail
14. How r:.any trips to do ask?
Signature,
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