2001_0804 WATER 4, ��I _
Issued: 4 ` °I Finished. Employee: ' �— � - - -- I "' " Grid map:
Nate:1< Um 1 Address: / : 0
Phone Number. (Fief)
Check for: Accuracy test: ✓ Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. g enair 3. Maintenance 4. Q h
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow 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: p_sL.Q.61..a.k.._ /1'` ���
61--9 / lam ti cam_
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: ?of (p /A Unit # Miles Hrs Equipment
A. Old Meter # ' , � .,� Reading 1 Pr es5.eft, s /
B. New Meter # ti 1 'Ili , x eading
C. Old Meter Size/Type: D New Meter Size/Type
E. Type of work performed or findings:
a 7 7s
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man-hours: Crew Members.
1 1. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
Signature A#2/./e//,11.91"