2001_0921 ((�� WATER 1 (L
Issued: Finished: I I – 2 Z - d r gcployee: . _ -4.� 4' Grid map:
Name: /�G%f�- /� Address: 7 ` A7,, „ _ ,_ •I
Phone Number (IN) (WK): 0 _ . - +
Check for Accuracy test Meter Leak: v Check water pressure:
Initial meter relocation iasae:doas Re -read
1. fiackflow Insp. 2. Repair 3. Maintenance 4. Q L
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
S. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment u site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: �/7zA.,o Ii �"t C' 1 7 .. _ a
7. If Meter: Se .ice Leak: Classify: - City: V Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Wu Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meer Cause Out Unit # Miles firs Equipment
A. Old Meter a 43 I FStreading /'I 74
B. New Meter 4 ' L y 1.3 92 Reading -
C. Old Meter Size/Type: D New Meter Size/Type
E. Type of work performed or findin : �
/JAL. ♦ L' . `l i a L L
i
9. If mainline or deep service rr describe type of pipe or service line and condition: .
10. Man- hours: 1 1—' Crew Members.
11. List Materials Used:
/ It e — . 4 s f 4 J°
1 2. If you had tr, ac :ide-ttr? :::dent while performing this request. Did you report :t' Yes or no
13. Water taleaes near iaspe:dan: or fail •
14. How many trips to do task? '
r A
Signature