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2002_0409 / WATER Issued: 9[ 9 /c7 Finished: VI / nZ EmpIoyee: Grid map: Name: Address: 1 1( . 1.4,011 9 Phone Number (HM) (WK): Check for. Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspections Re -read 1. $ackflow Insp. 2. Repair 3. Ma' . tenance 4. QSbct 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 B. Cones C. Tape D. Lights E. Other Request f o r Services: MFG ( t ' M1 0 3 7. If Meter /Service Leak: Classify: - 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 Meter Change Out: Unit # Miles Hrs Equipment A. Old Meter # 1 � 6056 Reading ,z2/ `94 4/ B. New Meter # �6, q / ,? So Reading a©oci C. Old Meter Size/Type: RAei t-/L D New Meter Size/Type 5 tip -44 t E. Type of work performed or findings: 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: 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? Signature ( , h I10 4 03