2000_1121 we tAl hoc=- A
WATER
Issued: < I 12-i ICO Finished:/ 1-3 0 b i) Employee: Ciir LA Grid map:
Name: ( la ' L hi�4 Q&in b 1 ko
M)
Address:
Phone Number: (H (;��L�il-. (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
Re est for Services: _' ti ill 1.. 1
a C* 1- . L i .-_ A 4
- i�• -1.\ C C 0.. •
../ ,
7. If Meter /Service Leak: Classify: - City: C ustomer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes �To
C. Was Customer Notified: Verbally t/ Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # 9 / Z Z / (I L / Reading / i'$f 7
B. New Meter # C./ /,S - goo Reading -6--
C. Old Meter Size/Type: a A o i„ L 2 // D New Meter Size/Type /'t, 0 s/4
E. Type of work performed or findings.
9. If mainline or deep service repair, describe type o pipe or service line and condition:
1 41 — e c%Po 570/"'
4 //2 AILX j„/LZk.
10. Man - hours: 2 d Crew Members. C 7" "'2 /i' 7
11. List Materials Used:
ri . 7e,t C,)N x171'7 t Oaf- / t x/17/1 e i,ef s�7,
12. If you had an accident/Incident while perform' this request. Did you report it? Yes or no
13. Water Utilities meter inspection: or fail
14. How many trips to do task? 3 'G
Signature