2000_0905 &L--; /Ai
WATER
I l t
Issued: �inished:
I t °t 4 Employee: Grid map:
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Name: 516A `'� a, . Address: C il
Phone Number: (HM) • Crai'��i a 3.% (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. BBar Cones Cones C. Tape D. Lights ght E. - Other
Request for Services: at at
at ,r u �t X / .
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 # Miles Hrs Equipment
A. Old Meter # / '1 S' / 0 Reading / 13ST
B. New Meter T Z L 42 4 10 6 ' Reading -6-
C. Old Meter Size:Type: D New Meter Size/ Type JAR %y P
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: , $ Crew Members. 6
11. List Materials Used:
e v -- r" 7e ?
12. If you had an accide ,t Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: as or fail
14. How many trips to do task?
Signature