2000_1018 WATER
Issued: 011 g IO ()Finished: Employee: q0QL Grid map:
Name:
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Address.
Phone Number. (HM) /
Check for. Accuracy test: ../ Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow insp. 2. Reoair 3. Maintenance 4.O.ha
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
4 k E. Safety
5. Reason for failure: A. Electrolysis B. Name 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: leS F (e -A �-�►
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 Verballj► Doorlmocker -
VehicleIEquipment Used
8. If Meter Change Outs Unit T Miles Hrs Equipment
A. Old Meter (12.3 4577 0 Reading D' (Po
B. New Meter 4 L 6 ' /L '7 v y Reading
C. Old Meter SizeType: D New Meter Size/Type ' 4 ' -1 4' f
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man -hours: j 3 Crew Members. 6-
11. List Materials Used:
/1 ! —7 €-
13. if you had an accidentIncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: �r fail
14. How many trips to do task? /
Signs