2000_0927 A el ( A 9 " "
WATER
Issued: �d4OPinish ` ed: -1 'O° Employee: (1' a i y Grid map:
22 C r .lI
Name: Le u Address: ( f0
Phone Number: (If) (WK):
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow 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:
rne4eir appec1r5 -t ry b g �
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 -
Vehicle/Equipment Used
8. If Meter Change Out Unit T Miles Hrs Equipment
A. Old Meter $ ? 1 N / ' D a Reading Z
B. New Meter 4 Z 6/2q !) l-f Reading
C. Old Meter Size:Type: D New Meter SizeiType 4b `� 1-40//t)
E. Type of work performed or findings: y" t ci/A
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members. 6, fi
11. List Materials Used:
A r)
1? If you had an accident while pe- orrn g this request. Did you report it? Yes or no
13. Water Utilities meter inspection: / -s or fail
14. How many trips to do task? l
Signature