2001_1129 C WATER
Issued: // M0/ Finished / / 2 2 l Employee: et In, y' gy
Name: W0i S .--- s l l't Ate: 9' S C ti
Phone Number. OEM) J (WK): o t
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial niece: relocation ns e:dors Re - read
1. Backrlow asp, 2. $ag,Y 3. Maintenance 4. Qihgt
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkftow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Celt Dace C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reuon for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
A. B. Cones C. Tape D. Lights E. Other
Request for Services: C V 1 a Inte et-
7. If Me:v. Se :ice Leak: Cass_; : - City: Customer
A. Water Lou (estira ): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker-
Vehicle/Equipment Used
8. If M ::e: C:a: 3e Our: Unit : Miles Hrs Equipment
A. Old Meter 4 6 6 Reading • •
B. New Meter 4 Reading ;i
C. Old Meter Size, ype: % New Meter Size Type
E. Type of work pefor=ed or findings:
9. If mainline or el service r d err� type of piper service line and condidon:
0 CA_ ,t a /141142 t n
10. Man- hours: Crew Members. /��'' -/, 7 7
11. List Materials Used:
12. If you had in icridentilnr.d :cc while performing this request. Did you repor : :t? Yes or no
•
13. Water Unlit:es meter its c :crt: pus or fail
14. How many trips to do task?
Signature 1/6