2001_0124 i2cdio C2LQ
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WATER
Issued: 0112410 Finished: J -2 G f Employee: 61CLIZAd
/A� Grid map:
Name: C�(_QiTC Address: 1�(.. 3 (/(.l.+C. beAci, Ott.
Phone Number: (HM) C i. 6 I (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance. 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. 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 •
Re u uest for Services: •j 1 / d• . . 1 1 At 1 •
7. If Meter /Service Leak: Class' City: Customer
Classify: - ty:
A. Water Loss (estimate): GPM Fire plu cashing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # 9 /22 / T 9Q Reading-.k a
B. New Meter # Z b '/ Z q Z `/ Reading
C. Old Meter SizeiType: D New Meter Size/Type . 76 0
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: 3 Crew Members. G' P
11. List Materials Used:
12. If you had an accident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection:. or fail
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14. How many trips to do task?
- ;` Signature