2000_0802 i!> L7e. t -
WA
00 >:: X22 0°
Grid map:
Name: ` J
-f l � l Address: ..�11 _ , l % •
Phone Number. (HM) (WK):
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Inso. 2. Basic 3. 4 . Q
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
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
n
riccadees B. Cones C. Tape D. Lights E. Other
Request for Services: OW t : Jt L) l J —
7. If Meter/Service Leak Classify: - City: C mer
A. Water Loss (estimate): GPM Fire p1u hing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Door]mocker -
Vehicle/Equipment Used
8. If Meter Change Out Unit # Miles Hrs Equipment
A. Old Meter # Z 32, 0 100 Reading
B. New Meter # 'Z /0 Yg ''7 Reading -6
C. Old Meter SizeiType: S g , s g / 'lei NeMeter Size/Type ) 7 e? /''Id/''7
E. Type of work performe or dings: S �, /
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: / Crew Members. / '.
11. List Materials Used: G j 4
12. If you had an accidentincident while performing is request. Did you report it? Yes or no
13. Water Utilities meter inspection: or fail
14. How many trips to do task?
Signature