2001_0504 WATER
Issued: Finished: " Employee: ,,e -( Grid map:
Name: Address: o ✓✓ s /w f , d
Phone Number: (HM) (WK):
Check for: . :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Llsp. A. Main Line A. Pump A. Line Locate
Bkrlow 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
Request for Services: /4]. � � e c4
7. If Meter. Service Leak: Classify: - City: Customer
A. W ater 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 U, ( i V Reading L S S) Z .2 9 30
B. New Meter 4 ".P. lG 2. 3. Reading je
C. Old Meter Size-Type: 54 1reAlsr'ok D New Meter SizeiType 0 49115fe?( 5.
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
Man- 1 Crew Merrbers. Li-- /
11. List Ma:e-:a s Used:
13. If you ':ad a : ac :ident :nt:dcnt while performing this request. D d you repot :t? Yes or no
13. Water Utilities meter inspection: -"pas or fail
14. How many trips to do ask?
/7
1(f
Signature .