2000_1110 / / WATER n
Issued: l I (10 /O'taisbed: j i lf/J, Employee: 41 Pi Grid map: �—
Name: l ii3 I ce .0 • Address: ! , � Cr
Phone Number. ('f) (WK):
Check for Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Reoair 3. Maintenance 4. Qtkr
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. Nam Construction C Poor Installation D. Other
6. List of safer/ equipment at site if applicable:
A. Barricades B. C C. Tape D. Lights E Other
Request for Services: kr 1 1 L�1 dt,i l J ''
.1 .
7. If Meter/Service Leak Classify: - ' : City: ./ Customer
tY
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified Verbally Doomlmocker
Vehicle/Equipment Used
8. If Meter Change Out Unit 4 Miles Hrs Equipment
A. Old Meter 4 gizmo 9 g Reading I.2 513
B. New Meter 4 2_ c Yl In e 0 Reading
C. Old Meter SizeType: 1 ct 4 s f F A 7 D New Meter Size Type i'7,.' -!77 5
E. Type of work perfommed or findings: C`► c -7 c'•7 1 e -44 ik c t`. 7
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. fan- hours: , S Crew Members.
11. List Materials Used:
NI ✓ j 42=1 e •2
12. if you had an accideat;ncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: "or fail
14. How many trips to do ask? -