2001_1108 WATER
Issued: // d Finished: Easployee ,
c ord gyp
Name:lA rrz> X11 n �� 9� �+ - //� >< .
Phone Number (104) C) ` (WK):
Check for. A:curacy test Meter Leak: Check water pressure:
Initial meter reloadon inspections Re -read
1. Hacktlow ULM, 2. &aC 3. Mains tea. 4. Q
Backflow insp. A. Main Line A. Pump A. Line Locate
Bktlow 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
S. Reason for failure: A. Electrolysis B. New Construcdoa C Poor Install:don D. Other
6. List of safer/ egaiptnent at site if appliabler
A. Barricades B. Cotes C. Tape D. Lights E. Other
Request for Services: T777 LAC
7. If Meters Se-..zce Leak; Cass_, City: Customer
A. Water Loss *taw.* GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Wu Customer Notified: Verbally Doorlmocker-
Vehicle/Equipment Used
S. If Me::: C.z=g: Out: q Unit :.Miles firs Equipment
A. Oid Meter +' / 243 70 (o 7 Reading 76 S7
B. New Meter 41 ,25 Re g O
C. Old Meter SizerType: f3 , ea a D New Meter Sizeffype %=►A STe't S// 3%y
E. Type of wort pcformed or findings: Nl FPM Cu /� s S Pat d
9. If =infirm ar deep service r - describe type of pipe or service line sad condition:
10. Maa- hct:rs: / Crew Members.
1 1. List Materas (:sed:
12. If you 4a_ sr. a :identr ?r: : : :: :t while performing this reques :. Did you report ;t7 Yes or no
13. Water L :(ices:meter icspec =crt: pus or ra :l
14. How many zips to do task?
Signature 4 ,e;rilLef