2001_0510 WATER
Issued: 5- ltb 0 ( Finished: $ i o Q Employee: Grid map:
Name: Address: C;L,S"S 4IPEiV k» Y
Phone Number. (Iii) (WK):
Check for A:curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re - read
1. Backflow Insp. 2. $Mit 3. Maintenance 4. Qt
Backflow L-tsp. A. Main Line A. Pump A. Line Locate
Blulow Cen. 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
S. 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: t4 g , o c7r
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
8. If Meter Change Out: Unit; Miles Hrs Equipment
A. Ord Meter # O0 ( 8S Reading / &S y
B. New Meter T S 1 021D Reading bt7l�
C. Old Meter Size.T pe: P (51nrt D New Meter Size/Type MRS/ l s/g
E. Type of work performed findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. `la'--c_ :. Crew Me -:e:s.
11. List Ma ::-ais Used:
13. If y eu ^ad 3:1 accident;:.::dent while performing this request. D :d you repot.: it? Yes or no
13. Water Utilities meter irsrection: pass or fail
14. How r:.a-iy yips to do ask'
Signature ,