2001_0202 /k LA} ti 6/ e
WATER
Issued:9la O1
Funs hed: Employee: lCU Grid map:
Name:l 5a1 - Address: ice. • i�, t1 • 0_
Phone Number: (I-LM) L ► a(WK):
Check for: Accuracy test•. Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow 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: , _ .,A
._ _ V
7. If Meter /Service Leak: Class' City: Customer
Classify: - ty:
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 # q L) / 7 0 V6 Reading /
B. New Meter # 4 / 2 . 1 2 s "
C. Old Meter Size/Type: 470
findi0 D s O fre C D New Meter Size/Type /e / et /I
E. Type of work performed r ngs:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: , Crew Members. 0'
11. List Materials Used: j
AI 12. If you had an accidenulncident while perfo 4' •g this request. Did you report it? Yes or no
13. Water Utilities meter inspection: .< or fail
14. How many trips to do task?
Signatur ��