2001_0813 00 Pn
WATER Ii
Issued: 1 3 O ( Finished: Employee: _ Grid map:
Name: ' - r, Address: t1z
O a - �1� - SLu _44
(WK): Phone Numb (WK): 3 to - 5
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. genair 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: .QQsL c,�� /-Z2sL L-4 �P
7. If Meter.'Serice 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 C:.a ge Out: Unit # Miles Hrs Equipment
A. Old Meter # `1,2 2 3173 Reading yG 7
B. New Meter # Readiiig
C. Old Meter Size/ Type: 5 f(�C y �f/f f eA"D New Meter Size/Type 7. 37 /141Te i
E. Type of work performed or findings:
N ,fir 2 5 T u c Ogpsrf
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: l Crew Members. /' /z 5 411 �7�a=✓
11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you repar, it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
Signature