2001_1119 WATER
Lssued0 /9-n/ Finished Employee: C. ✓)Y1(
Grid map: _�---
Name: � Address: Q Cn c lz j — ',lz ( A:
Phone Number (HM) (WK)
Check for Acetracy test Meter Leak: Check water pressure:
Initial meter relocation sar.+rdor.s Re -read
1. Backrlow asp, 2. Repair 3. Maintenance 4. Qslier
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkftow 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 Construction C Poor Installation D. Other
6. List of safety equipment u site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
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Request for Services: r r rnto re
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7. If Meter: Se: ice Leak: Cass_;: - City: Cus:orer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Wu Water Metered: Yes No
C. Was Customer Notified_ Verbally Doorlmocker
Vehicle/Equipment Used
8. If Me: :: C;.a: ge Out: Unit # Mies Hrs Equipment
A. Old Meter / 9 /x.2 3 b Reading .2/ Pea
B. New Meter 4 ad 94. s Reading r)
C. Old Meter Size/Type: 5 /y 'iT -- D New Meter Sizeffype cie
E. Type of work pefor ed or findings: X PISA- ,' /22z.-7
i.9
9. If mainline or deep service - describe type of pipe or service line and conditi • // -
10. Mar.-howl: Crew Members.
11. List Materia.s Used:
12. If you hzd as ic:4e aT t. eat while performing this request. Did you repor. :t' Yes or no
13. Waver Ualiaes meter icspc :cn: pass or fail
14. How many trips to do task?
Signature