2000_0403 - . ()C- ----4"n'. .,
WATER
i
Issued: 3 Finished: q--5 �: t Employee: ,,' ✓ Grid map:
Name: Address: /.... / 1 • '. / Al ...i it- ! t- " A" /
Phone Number: (:LEI) (WK): 1
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backrlow Insp. 2. Repair 3. Maintenance 4. Other
Backrlow Insp. A. Main Line A. Pump A. Line Locate
Barlow Cep 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. Con C. Tape D. Lights E. Other
Request for Services: ch...e.Z1-1., 7
7. If MeterService Leak: Classify: - City: Customer
A. W ater Loss (esern ate): GPM Fire plug. flushing Total Gallons
B. Was Water Metered: Yes / No
C. Was Customer Notified: Verbally . � Doorlmocker -
VehiclefEquipment used
3. If Meter Grange Out: Unit 4 Miles Hrs Equipment
A. Old Meter = Reading
B. New Meter T Reading
C. Old Meter Size Type: D New Meter SizeiType
E. Type of work performed or findings: 'j P s ki iif i, /.54 l' -4. v, S eq .S , - 41
/- L iPowLc ;:t .6"/ ,f AR: tw6 /14 i /t v /i cc..• / =%6Cc
9. If mainline or deep service repair, describe type of pipe or service line and condition:
.._—
10 . `.I37. ,c_.. , f Crew Members. C.7)
11. Lis: Materials Used:
1?. If; ;u had an ac ::de- ::.::dent while performing this request. Did you : por, it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do ask? /
S.gnature ' 1,