505 Airline WATER /
Issued: Finished: Employee: e d Grid map:
5 "S 1 ri L►',t�?
Name: Address: Home. 459(9..
Phone Number (FLM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Dacktlow Insp. 2. j.epait 3. Maintenance 4. Other
Backlow L• sp. A. Main Line A. Pump A. Line Locate
Bktlow 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: Sa } i r . - i J►-t F. fe e h c. N P Li-/-
11 M P - ifle-
7. If Meter :Service Leak: Classify: - City: - Customer
A. W ater Loss (est ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknockcr -
VehicluFquipment used
3. If M_ :e- Caange Out: Unit 4 Miles Hrs Equipment
A. old Meter c ?/7.23S 0 Reading A. /6'e Y
3. New Meter 4 .2-1)6 1 0 Reading
C. Old Meter SizeT jZ `t f PyCgle it,/ D New Meter SizetType "{'�/� {�)
E. Type of work performed or findings:
9. If rrai: line or deep service repair, describe type of pipe or service line and condition:
10. eta ...: _.. ^ lS Crew Me -:e s. U
11. Lis: Ma :erials Used:
4/ oaf d
11. If =ad i t accident".. while performing this request. O d you repor Yes or no
13. Water Utilities meter inspection: or fail
14. How .r.aiy nips to do ask'
Signature