2001_0924 Iv 4/ /4 e-- - 7e
WATER
Lssued: �- �� Finished: _: 9 p / Employee: I' Grid map:
Name: — j Address' L -
Phone Number. ( L/ (WK): / •
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial mete: relocation inspections Re -read
1. Backflow Insp. 2. $snail 3. Maintenance 4. gthel IU
( a i
Backflow Insp. A. Main Line A. Pump A. Line Locate lc, �--"?
Bkflow Cert Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap /,J
D. Hydrants D. Equipment D Excavation ' , l
E. Safety
S. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other ��
Request for Services: _ -4.,p, t97 t, � -e.
i 2 -4 ,- /et, 7. If Meter: Se :ice Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Mere: C;.arge Out: Unit # Miles Hrs Equipment
A. Oid Meter Oq$'Brl Reading 7 y �l 1
B. New Meter # 9ya-3 2 r Reading k,
C. Old Meter SizeiType: t")...- /mot / 7 ' D New Meter Size /Type Pt ,,i. /Li 2"
E. Type of work performed or findings: Pi 1 did I Ii --
9. If mainline or deep service rr describe type of pipe or service line and condition:
10. Man - hours: g, 0 Crew Members. b 6 " 'T1r
11. List Materas Used:
/d -v M h41e _eV ei4 RQ 473/ /p' t .4"
12. ((you had r accident/Inc:dent while perfo ' g this request. Did you repor. it? Yes or no
13. Water Ualines meter inspecnon: or fail
14. How many trips to do task? L
Signature /'./1/7