0415 WATER .
Issued: 4 /1 S Finished: - 6S ■
Employee: .d . Grid map:
..ig Name: �i d Address: V S Ri Q e
// b ►► er. � � 222 (�
S t Phone Num �'' � _
C ' / c9/ 4- .3c/- Sol z
Check for: Accuracy test Meter Leak: Check water pressure:
.. Initial meter relocation inspections Re -read
gt...... + 1. $ Other
ackflow Insp. 2. Repair 3. Maintenance 4.
" Backflow Insp. A. Main Line A. Pump A. Line Locate
1 , .---. lig 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
* t 4
5. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
•� _ 6. List of safety equipment at site if applicable:
A. arricades . Cones C. Tape D. Lights E. Other
Request for Services• to P ( lt.t D u. 4C r-
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7. If Meter /Service Leak: Classify: - City:
Customer
en i g..
A A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
,5 B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
y Vehicle/Equipment Used
g 4 i Unit # Miles Hrs Equipment
n
• 8. If Meter Change Out: A. Old Meter # . • _ 7 Reading �[
1� B. New Meter # , `� j► al Reading
* 1 Qt C. Old Meter Size/ ype: D New Meter SizeiType
E. Type of work performed or findings: &+u: t t Lie Ines k rNlQ j ,., i -1- 1 xn____s.rauSc
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EK oI c,c . Nc .. • • ..a Q • s i e • . . AA' -to see ,se ;,c-i.
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A 9. If main o r d 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 nips to do task?
Signature