2001_0730 7 WATER
Issued: / ° 7 �� Finished: 2 3 a Employee: Grid map:
Name: / ,/�
02✓6 a 2 .e- A dress: S Y5 "4 „-- 4s<A._
Phone Number (HM) (WK): '3 (o q .7
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. Other
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 for Services: (,�4i ri t1L pi..,44 9 - .A•< -1, VL G Vn
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 # • $ Reading 6 3
B. New Meter # ;.OILS l i Reading di"
C. Old Meter Size/Type: ' crs /be ' New Meter Size/
E. Type of work performed or findings:
9. If� a o//r, a service air, describe type of pipe or ser ce line . and con 'on: _
/ 1 1 / / rn oler C.r� .5P4 f ,c5 b P frsM
10. Man - hours: Crew Members.
3�
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
Y
14. How man trips to do task? "
Signature