0928 oftre ofi
WATER
Issued: - ( o Fiaisbed Employee: L4 Grid cop:
, a 43! Address: s ( _� � , 1���e�, -� - .
Phone Number (FLtii) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backrlow lase, 2- Re pair 3. Maintenance 4. Qxt
Backflow trip. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Due 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 sue if applicable:
Barricades B. Cones C. Tape D. Lights E. Other }
Request for Services: l -v--QJ� .
7. If tie :err Service Leak: Cass_, City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Tone Gallons
B. Wu Water Metered: Yes No
C. Wu Customer Notified. Verbally Doorknocker -
Vehicle/Equipment Used
3. If Mete: C,:a:ge Out: 1JJ�! Unit # Miles Hrs Equipment
A. Oid Meter 4 3 Reading 5 2 t/it�I
B. New Meter 4' Reading 4)
C. Old Meter Size/Iype: /21/k D New Meter Size/Type LAMP' A/
E. Type of work performe • :r Endings
.� 4t.
.. i £ �4 .
9. If mainline or deep service r_ - describe type of pipe or service line and condition:
10. Man- hours: / Crew Members. 2'•
1 1 . List flare ^as Used:
12. If you ham z icr :dety ?-::::tit while perforating this request. Did you repot.: :t? Yes or no
13. Water L'aitaes :netcr iespe::crt: pass or fail •
14. How may trips to do task?
Signature ° s. _