2001_0804 Ciji,
WATE
Issued F-9, of Finished b E�toyee. a.t<•1•� gr A Grid ma
Name: / Addresst
Phone Number. (KM I (WK)
Check for. Accuracy ter: Meter Leak: Check water pressure:
Initial meter relocation inspe:dons Re -read
1. Backflow Insp. 2. Renail 3. Maintenance 4. Othet
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent. 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: - P - I 3 1 0 1 L I
E
7. If Meter: Service Lek: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorlmocker -
Vehicle/Equipment Used
8. If Me :e; C:an ge Out: Unit # Miles Hrs Equipment
A. Oid Meter 4 IV° N Lo ?<y
75 CI \ Reading 6OOa3 - a 0 / 0 3 1 G 0
B. New Meter 4 2-(e Li l 3 q . Reading ( _
C. Old Meter Size/Type: sib rnyf Y D New Meter Sizellype
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man -hours: l /
Crew Members.
11. List Materials Used:
12. If you had a:: accident .;:dezt while performing this request. Did you report :t7 Yes or no
13. Water Utilities meta iaspec :on: or fail •
14. How many trips to do task?
Signature 1� r 1 , 0)