2002_0627 WATER
Issued: 6--21- 01. Finis ed: Employee: Oar lit- Grid Map: , ,
Name: oft V1UI t bb rG iltirrian Address: 16 Kincjehin-
Phone Number i):
C� (WK): _
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Emir 3. Maintenance 4.
Backflow Insp. A. Main Line A. Purnp 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
S. 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: N1i
rez -Ar aea.raej
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
8. If Meter Change Out: %
A. Old Meter 4 p2/ /7 / / 3Z7 Reading .2 3 0)5 74'
B. New Meter 4 ,;e6 q (13? Reading 9
C. Old Meter Size / Type 13 L, � e New Meter Size / Type s/ Aft a '
E. Type of work performed or findings: l,-h er . ,IYli4*0 /)t24 d rc" c- v>zAc':c. j ---e4
9. (t mainline or deep service r':a_. describe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date 1 -1_02 I pages ■ ?.
10. Nfan hours: Crew members: To KAY 0 Nnf 5cNI From DE$l I Nelea m
1 1. List materials used:
Co. /Dept. BILL I N(1 co. UTI L l TI 65
Phone # Phone #
Fax # Fax #
12. (; you had art accident incident .4 ile 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? 4„.4; /14.e-4-.-___-----
Signature