2001_0919 0 19AP 1/41
I •
WATER Z
issued: Finished; E '/ /AA,. ,
c / . Grid map:
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Nae: /!� LGyI @ ,) / j Address: '
Phone Number. (10.4) (WK):
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Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspe :noas Re -read
1. Backflow Insp. 2
RroaiC 3. ane,q, 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. Equipment D Excavation
E. Safety
S. 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: Ile .C1e 4
7. If Me: Se .ice Leak: Ca;;_; : 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 Me::: C:a: ge Out: Unit T Miles Hrs Equipment
A. 0id Meter 0? C97---S Reading 7:g8 6 O
B. New Meter 4 IgiA " 7 Reading f)
C. Old Meter SiwT; pe: ; r e ' '. D New Meter Sizei Type 6
E. Type of work performed or dings: n1£ -1
AN v . ...
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: I Crew Members.
11. List Maters Cased:
12. If you had in accidcau ?-::::tit while performing this request. Did you repor.:t' Yes or no
13. Water Lalioes meter irspe: ;en: pass or fail
14. How nvny trips to do cask?
Signature KO,- 1'