2001_0523 _ .
WATER
Issued: Finished: - e3 caployee: M d Grid tap:
Name: Address: V- C A i f L i M'e
Phone Number (FFev) (WK): /-/ B pi, e S d -
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $acktlow lnsn. 2. Repair 3. Maintenance 4. Other
Backlog• 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: 1 4 2 5 J.7 e I t.I e/ fn r r L 1 `n1
2 - Prefer C �a ►V d e 0 u-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 Doorkaocker-
Vehicle/Equipment used
3. If Me ::: Ccange Out: ¢ / ( Unit 4 Miles Hrs Equipment
A. Cad Meter 4 517 z 35 - Reading _ _ j` 70
B. New Meter 4 2. ie (Q l a/7 Reading
C. Old Meter Size.Ty c: New Meter Size/ Type
E. Type of work per- or findings:
9. If train li:e or deep service repair, describe type of pipe or service line and condition:
- 2 fK5
10. NIa- -._:. 4 7 Crew M: -ce:s. j'" / 1
i
11. Lis: Ma:trials Used:
12. If ;.cc =id a t czident ::.cadent white performing this request. D r you rarer.:? Yes or no
l3. eater Utilities meter irsection: ass or fail
14. How mazy nips to do ask'
c ,, 1
Signature _ . -- ___