2001_0830 WATER
Issued: f # : ° /Finished: I— Employee: Grid map:
Name: Address: AQ a._ n
Phone Number (ELLS) (NW):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Ins. 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
Request for Services: /11.......) ! p/ l� ,4 ,
/ i i e ( L Ct tar ca. t.► 5e- Oar
7. If Meter:Se :ice Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered Yes No
C. Was Customer Notified Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Cha ge Out: / Unit # Miles Hrs Equipment
A. Old Meter q / b256 l4eading D5 . G p 9 20/0 370
B. New Meter # '2 l ,-(617 Readin ()
C. Old Meter Size/Type: D New Meter SizelType 54c /r /1 f StS't
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: / til Crew Members.
11. List Materials Used:
12. If you had an accidenvincide :t while performing this request. Did you repor. Yes or no
13. Water Udhnes meter iaspecdcn: /� or fail -
14. How many trips to do task?
Signature J\, pJ C 7 " C J