Untitled (13) WATER
Issued: I Finished: X0 (2 S Employee: 1 ( . . � Ti4 - e Grid Map:
Name: Address: / c l (T/lI�.I =� (n!
Phone `umber (FEND: (WK):
Check For: Ao:ar_: • Test Meter Leak V Check Water Pressure
Initial Meter Refec_::cn Inspections Re -Read
1. Backflow Inso. 2. Reoair 3. Maintenance 4. Other
Backflow Inso. =.. Main Line A. Pump A. Line Locate
Bkflow Cert. Date 3. 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 ;' applicable):
A. Barricades 3. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: /1/41 C !/r *Al /4_ G u,±
7. If Meter / Service Leak. Classify: City Customer
A. Water Loss (estimate): G ?M Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Custcr-er Notifies: VERBALLY DOORKNOCKER
3. If Meter Chanze
A. 01d Meter = 4 7 3' 73 & //V Readinz 50 ?J1
B. New Meter = v-t oc g/ 5 Readinz
C. Old Meter Size ' T . :e `�/r Y 3 `1 /d /3/Kiy New Meter Size I Type S -4 ' 4 i /9145/
E. Type of work cer :rmed cr -dings: ( )/s ir-, fi_-/'/ -
h.-f +o, k,16. 0Lo:r
9 If ,,. ,dine :r .ee_ __. describe type of pine or service He and condition:
10. flan hours: 1 / Crew members:
f 1. List materials u .. se � 1 e c (- , _'- !1/41.,
l 2. fi you had an ac:i(ler: ncid-a ^,ite performing this request. did you report it? YES o NO
13. W.ucr irspecccn PASS or FALL •
14. How many trios to :o :ask?
Si;nature