2000_0403 WATER O
Issued: Fed:/ ' -t7 Employee: / Grid map:
Name: Address:
Phone Number: (KM) (WK):
Check for: Accuracy :est: Meter Leak: Check water pressure:
Initial meter relocation inscections Re -read
1. Backrlow Insp. 2. Repair 3. Maintenance 4. Other
Back low Insp. A. Main Line A. Pump A. Line Locate
Below Cep 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
Request for Services: � ili�-
7. If Meter/Service Leak: Classify: - City: Customer
A. W ater Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes / No
C. Was Customer Notified: Verbally c,/' Doorlmocker -
Vehicle/Equipment Used
3. If Meter Change Out:: Unit T Miles Hrs Equipment
A. Old Meter = Reading
B. New Meter T Reading
C. Old Meter SizeType: D New Meter Size:Type
E. Type of work performed or findings: Li Dc e 1 61-,t( /L' e 'f e
'/lis l' . ✓ aG •r e ,,,✓/ S c f7e 4 v, o 4 -5 .. •
`140t 4'T t ,t-
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. `.1.- ... 1 Crew Mem'zers. C s /
11. Lis: Mta:erials Used:
1 ? . If ; u had an ac =:Cent :..cadent while performing this request. Did you report it? Yes or no
13. Water Utilities meter iasp.ection: pass or fail
14. Flow .;any trips to do ask.'
Signature !vv`i