2001_0906 WA 1' '�
Issued :J "/Z 01 Finished ,1
Employee: Grid map: n , - ,
Name: Address: S a pUC/I ►1AJUClIs,�
Phone Number. (KM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. flackflow Insp. 2. Repair 3. Maintenance 4. Other
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. Equ±pment 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:
in E -r2 fZ C Lt a Ile 0 u
7. If MeterrSe -ice Leak: Classify: - City: Customer
A. Water Lou (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Mete: Cha ge Out: Unit # Miles Hrs Equipment
A. Old Meter # 2 b �4 J 5 al. C Reading 47
B. New Meter # 7, fp 1 Y10 Reading (Q
C. Old Meter Size/Type: 5/57 ot; D New Meter Size/Type iR. E_
E. Type of work perforzted or findings:
9. If mainline or deep service re- describe type of pipe or service line and condition
10. Man - hours: ` )� 1
Crew Members.
11. List Materials Used:
12. If you had an a ccidenti1ncide :t while performing this request. Did you report :t7 Yes or no
13. Water Utilities meter inspec:icn: p& s or fail •
14. How many trips to do task?
Signature `t\ ! 1 £ 0 6