2001_0228 N 1 W 1 ei t t
WATER
Issued: Z - & - n/ Finished: -L 8' c1 / Employee: it 4'' )/ Grid map: __________
Name: Address: / 3 0 AO /7 N ✓/! LI _
Phone Number- (HM) (WK): l
Check for: Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Fair 3. Maintenance 4 . Qther
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
5. Reason for failure: A. Electrolysis B. Now Construction C Poor Installadon D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: 7 7 e,? d .a GK // ac , 4 7 '97,: i r
v .
7. If Meter/Service Leak: Classify: - City: / Custome
A. Water Loss (estimate): GPM Fire plc flushing Total Gall
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorlmocker -
Vehicle/Equipment Used
• 8. If Meter Change Out Unit ft Miles Hrs Equipment
A. Old Meter 4 ei 2 // 9'i / S' Reading 23.3 6 ?
B. New Meter 4 Z. G `/l a e., Reading
C. Old Meter SizeType: 576 - B/) i D New Meter Size/Type J78 n-#1,
E. Type of work performed 66r findings: , l oa 4, » , , ) 6d c ry •2? s 70 p
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man -hours: 2 • 5 — Crew Members. G ' • G"J
11. List Materials Used:
he7e? Lao P ,- We. v/ .- -le 2 -GK.te -s
l?. (f you had in accidenti tcident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: or fail
ti 14. How many trips to do task? 3
Signature