2000_0703 •
WAIT
a?ER
Issued: € 9 d41xiisbed:. Grid map:
race: Adre s: i9
Phone `umber (FLM) (WK):
Check for: accuracy :at: Meter LMf: Check weer pressure:
Iait«al serer relocation iaseeczons Re -read
1. Back flow lam, 2. &Pik 3. Mainalnegat 4. Qligt
Backlow tarp. A. Main Line A. Pump A. Line Locate
Cert Date B. Valves B. Water Tower B. Line Locate
Re-C Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reason for fagnre: A. Electrolysis B. New Costa tnedon C Poor Instdiatioa D. Other
6. List of safety equipment at sins: if applicablc
A. Barricades B. Cones C. Tape D. Lights E. Other
Regy�estf es: _/ !__% /�_'� L_.� = _
7. IffiletenService Lak Classify: - City: Customer
A.Water Loss (rate): GPM Fire plug flushing Total Gallons
B. Was Water Mane& Yes No
C. Was Customer Notified: Verbally Doork cker -
VelticletEquipazent Used
3. If ` :::_-Cringe C.: Unit *Miles Hrs Equipment
A. Ord Me:er = 0 .S — fib'/ Reading /L bh 1.
3. New Mere: = 0 Reading .0—
C. Old Meter SizeT :pc: D New Meter Size sype J /P Ot -? �y J d!z
Ejype of work performed or findings: O "&/r , / /ea
1"7 4 7e �i /'i - ? /,v4�/�>c ou
9. If :.-a 1;me or deep service repair, describe type of pipe or service line and condition:
/ J Cr_
1 1. L:s: `.ri :r-a :s Le;
/1/e LA) r'i e
I '. if; w'r.. :;e performing this re: D1d :ti
l3. Wrer Utilities meter erection: / p or fail
14. How =any trips to:oIsk? l