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2001_0508 • WATER Issued: Finished: Employee: m 6 / oc Grid map: Name: Address: 2 J15 Phone Number: (NM) (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 Bkrlow Cert. 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. Cones C. Tape D. Lights E. Other Request for Services: 5 j ,c 11 cG' r c ,ii E .l r C' y Ci v2 y e. 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 - Vehicle/Equipment used 3. If Meter Change Out: Unit 4 Miles Hrs Equipment A. Old Meter 4 q© C '3 c' 1 5 Reading c55 5 l - 2 3C A Re B. New Meter 4 2(e 7 55 Reading C. Old Meter SizeType: 5/Y /' G SrL \) D New Meter Size/Type 5 i'diiv- tj - ' E. Type of work performed or findings: 9. If mainline or deep service repair, describe type of pipe or service line and condition: :0. Man-hours f 14.< Crew Members. t.1'1 11. List Materials Used: 12. If you had an accidentlhcident while performing this request. Did you report it? Yes or no 13. Water Utilities meter inspection: 'as or fail 14. How many trips to do task? Signature t fig' r