2001_0109 r 9 WATER
Issued: / I Finished: / ' Employee: -iP f-r Grid tap:
Name: Address: / yr C 4
Phone Number i.FINIl: (WK):
Check For: A:c..:racy Test Meter Leak Check Water Pressure
Initial Meer Re(cc_: :on Inspections Re -Read
I. Backflow Inso. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dace S. 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. Cores . C. Tape D. Lights E. Other
REQUEST FOR SERVICES: (1 ,,,.,- e m Ir ?-p-c}„., //rs/ h / 1,
7. If Meter / Service Leak. Classify: City Customer
A. Water Loss (estimate)): GPM Fire Plu Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Yotifled: VERBALLY DOORKNOCKER
3. If Meter Chance 0a ::
A. Old Meter _ /5 7/S Reading /,-) 0 7(')
B. New Meter = JO -74 ') . 7 Reading
C. Old Meter Size ' Tv :e New Meter Size / T e
E. Type of work performed cr = :dings: a,,.� „ 12 " ,J .,d 1, ,e.�
9 lr 7,1 , nline or t:e : :e - ce -__:.-. describe type of pipe or service line and c:ndition:
(---) .
l0. Nlan hours: Crew members: ' . ,- _ i
f
L. List materials '.se�
t' (t you h.J an ciL:ent,: widen:...hile performing this request. did you report it? YES or NO
l3. Water L'tditle) meter inspecticr. PASS or FAIL
l Ho'.. many trios to do task' . /
it
Signature