2001_1108 WATER
Issued //KC)/ Finished: Employee: ( _
Name: U i - c Address: a
Phone Number: (K) (') (WK):
Check for. A ::u. cy test. Meter Leak: Check water pressure:
Initial mete: relocation ripe :does Re -read
1. aacktlaw Ipso, 2. $Myi 3. Maintenance 4. Qih
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves 9. Water Tourer B. Line Locate
Re -Cent. Dace C. Service Line C Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reason for failure: A. Electrolysis B. New Coustrucdon C Poor Iastalhdon D. Other
6. List of safety equipment at site if applicable:..
k 3arrieades B. Cones C. Tape D. Lights E. Other
Request for Services: {I' }e7pi(
7. If Me ::r. Se :ic: Leak: C:us_ City: Customer
A. Water Loss (estimate GPM Fire plug flushing Total Cralloas
B. Was Water Metered: Yes No
C. Wu Customer Notified: Verbally DoorkDocker-
VehiclelEquipment Used
3. If Nis::: C; a: g: Cut: Unit R Miles Hrs Equipment
A. Cad deter ; 7).1/ 7/ '7 Reading / e 6 7
B. NeW Meter * 1 Z Rea g C.2 Y
C. Old Meter SizeiType: UftelyeR 2 /5( D New Meter Size Type #S e /2 ✓ r • "
E. Type of work pc-formed or findings: /-v JeR 5Tv (if< — � � / /Je e /
9. If mainline or deep service repair, describe type of pipe or service line and cocdidon:
10. Man - hours: Crew Members.
1 1. List Materas Used:
12. ((you had 1- te:identir::.: :a while performing this request. Did you repor Yes or no
13. Water (;:hoes .meter icspe:_cn: pass or fa:;
14. How many sips to do ask'
Signs