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2002_0507 WATER Issued: Si 7 / ©z Finished: 5, 7 io ?_ Employee: Grid Map: Name: Address: -Z21.1 J L, A- .P/ x Phone Number (HM): (WK): Check For: Accuracy Test Meter Leak Check Water Pressure Initial Meter Relocation Inspections Re -Read 1. Backflow Insp. 2. Bat 3. M 4. gad 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: t46464--- (tom 1 e- () 0 4'" 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 R 91a a % S5 Reading / / o L B. New Meter ;# Reading g C. Old Meter Size / Type Pe/L(1 IpA New Meter Size / Type 5' MASS E. Type of work performed or findings: 9. If mainline or deep 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 accidentincident •. hile performing this request, did you report it? YES or NO 13. Water Utilities meter inspection: PASS or FAIL Jw How many trips to do task. 14. Ho Y Signature