0725 WATER
Issued: Finished: 9 ,1, , X Employee: ; Grid map:
Name: /9/ j Address: 4 4 4/ 5 (
Phone Number:,IIvi i ) (WK):
Check for: Accuracy test: Meter Leak: v Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 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: c5 gr U it e 1 IA e. ff 1 free
7. If Meter /Service Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes 17 ./No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles His Equipment
A. Old Meter # I ; I Reading 62
B. New Meter # , i7 ` Reading
C. Old Meter Siz ype: New Meter Size/Type —
E. Type of work performed or findings:
9. If mainl' a or 4eep ervice repair, describe type of ipe r service line and condition: /
/ e rc tv/re /, n e i e� /ce- ( Jirh shy), /rr 1 1c. '
10. Man- hours: Crew Members. 6
11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail •
14. Flow many trips to do task? --in
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