0226 WATER
Issued: ,J , Finished: - — Employee: - : a Grid Map:
Name: „, , ; )( 1-k f 17 CO, ;
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read c
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other 4 ,
Backflow Insp. A. Main Line A. Pump A. Line L a
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Bkflow Cert. Date B. Valves B. Water Tower B. Line L g 1 — 3
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D. Excav: it
E. Safety o LL a LL
5. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation D. Other _
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6, List of Safety Equipment at Site (if applicable):
A. Barricades B. Cones C. Tape D. Lights E. Other o
REQUEST FOR SERVICES: ' r( t',,,,, , , _,.”' /11.• " = t c �.� c ) /-< 1 o Cf) CD
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7. If Meter / Service Leak, Classify: City Customer ° F- a LL
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A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out: L/ v ,-
A. Old Meter # 8 , 7as /� ,-7 Q 7 Reading / / i /6 6
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� P} .... B. New Meter # :7) `� /( 7 1..� � Reading
C. Old Meter Size / Type New Meter Size / Type
1 ;1
E. Type of work performed or findings: t � .. � ,,,,� �.;i C1-L. & e,1, -, .� - .t4 ..,_,4 1
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members: -2 -- /
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?
- li 4' 1 Signature