2000_0410 / WATER
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Issued: 7 -/ d - Finished: y'l/ Employee: me./ 6 Grid map:
Name: (4)il+eye F I �(t`►� Address: 4 0 7AKK /(C/h lib
Phone N=t:er• (KM) (WK) (/
Check for: A :curacy test: Meter Leak: Check water pressure:
Initial me ter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backilow Lisp. A. Main Line A. Pump A. Line Locate
Bkrlow C. Date B. Valves B. Water Tower B. Line Locate
Re -Cer 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 L C. Tape D. Lights E. Other
Request for Services: e -(e 1Z ; nl by k c.JGvf t�
7. If Meter. Service Leak: Classify: - City: Customer
A. W ater Loss (estii ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
3. If Nfe :e: C::ange Out: Unit 4 Miles Hrs Equipment
A. Old Meter ,# Reading 1/ " v� Fib /
3. New Meter 0 / C Reading =XX
C. Old Meter Size.Tyne: D New Meter Size/Type /1/45 012
E. Type of work performed or findings:
fiu Rnl Pttfrrt #- 5Pl- t1lC.2 Zin)e
9. If maim E to or deep service repair, describe type of pipe or service line and condition:
10. \ta : - _ _.. ! � 5 Crew Me...::e:s. r
11. List Ma Used:
1?. [f y c;. i : accident :.-_:dent while performing this request. Did you report :t? Yes or no
13. Water Utilities meter inspection: or fail
14. 1{ow .:..a y trips to do ask?
Signature X, / 1 /