2000_0815 x.aiclio I. WA l- , q •e) 1 --- e
WATER . •
Issued: 40 Finished � - v a Employee: GaaA Grid map:
Name. n — TCrY1 LU a Address:Q Q(9 1Q-C & Ut air:
Phone Number (HM) "SMMAri��0 • ' ):
Check for. Accuracy test: Meter Leak: Check water pressure: .
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Egg& 3. Mme. 4.
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 silo if applicable:
I A. Barricades B. Cones C. Tape D. Lights E. Other ..
Request for Services: LQ .
7. If Meter/Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug ' g Total Gallons
B. Was Water Metered Yes No
C. Was Customer Notified: Verbally Doorlmocker -
Vehicle/Equipment Used.
8. If Meter Change Out Unit # Miles Hrs Equipment
A. Old Meter # if 034 D Reading / l Z6
B. New Meter # 1..e 5/Z Reading
C. Old Meter Size/Type: o 43 . 4/9 P 4-i D New Meter Size/Type -74 4'- /r* /'h o L/'/
E. Type of work performed or . dings: /4-7 4.70 e L- %o v>
o a— `� . L G, sr '
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: / Crew Members. (r ,
11. List Materials Used:
Ai•- , i V I' 1 , , ! L 4 L a ? P A"U P 014, " P G l'e f
12. If you had an accidentlncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: p or fail
14. How many trips to do task? 2-
Signatur �i(/�✓