2001_0806 WATER SW11
Issued: 3 / Finished: - ( -v ) Employee: Grid trap:
Name: 7 " l 0. — fit/ Le-Z-/ A 13 �p c r
Phone Number. (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. Qte
Backflow Insp. A. Main Line A. Puxnp 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 site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: [ L a a 9,
C / /i1 !L &.r !-L - - -
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: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # ) 1.7' 7 Reading 9 3
B . /0- New Meter # as"' 7. 3 Reading 0
C. Old Meter Sizerrype: 3 J43 remA) New Meter Size/Type 5/t( )C 1 /) S tere..__
E. Type of work perfotme or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
pp
10. Man- hours: I S Crew Member. fig S `
11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail •
14. How many trips to do task? 41) 6i
Signature