2001_0831 3 18 - .J /
3 / WATER
Issued: - ��' � + F in ished
Employee: •� Grid map:
Name: Address: L�Y ht a..p �,�.,. ,..... If Y r....A.c.t. ji-+ -
Phone Number (KM) (WIC): .,.24
Check for. Accuracy test: Meter Leak: Check water pressure: frere--.
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Beak 3. Maintenance 4. Other 4
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: " Y — a.X fi st
" 4.491"' ./ 0 9,
7. If Meter: Ser<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 Meter Cra ge Out: Unit # Miles Hrs Equipment
A. Old Meter ; a 1 g5 C5"Reading 94w
B. New Meter # a4 yl 3S (. Reading b
C. Old Meter Sizeffype: D New Meter Size/Type
T f of wo performed findings:
& l�/1e4.t7
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you repot it? Yes or no
13. Water Unlines meter iaspec :on: pass or fail •
14. How many trips to do task? - ).-------
Signature 7://
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