2001_0510 •
WATER
Issued: 5.--/ 0 - t. Finished: ( Employee: Grid map:
Name: Address: 30 3 p.c t.> I.a Q
Phone Number: (1-LM) (WK):
Check for. Accuracy test•. Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. impair 3. ; Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bu1ow Ce .. 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: M E'T e 4 03
7. If MeteriService 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 `(' eN 1 Reading 11 ?..S
B. New Meter 4 2$1 Z i a2 Reading dc, ' f
C. Old Meter Size-Type: 54 - 0 10‘ 7 1 4 1 n N D New Meter Sizeffype S/k MA.S'TEZ.
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
1+0. Nfa- -c_.. Crew Mem:ers.
11. List Nta:e::als Used:
12. If y eti ^ad a: accident::. ::dent while performing this request. Did you repar: it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How .:.ray zips to do :ask'
Signature