2002_0129 Post -it® Fax Note 7671 Date `((` ,00�0�,, Ipa 1 WATER ••
To thrtson From Dakie, � I ax� 1
co./Dept. ye�� C�lTi Grid slap
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Phone # c if Phone +ddress: ____112_0,1 ''
Fax # Fax #
CWX)
7.7102e LOr m iv...a...
Check for: Accurac taw_ Mar Laak _ Check water premium maw saccades inspecting �*+d
1.Backflow intro. 2. Reoaix 3.Haintenance l•Other
Backfield Insp., s A.Line Locate
a.Main Line A.Pump
B.Valves B.Water Tower H.Inspection
Bkflow Cerr.Date C.Service Line D :c� nt D.Ex
D .Hydrants qu p
Re-Cert. Date
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
o. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman: / 1 / 44E4- C n�A "
=f Meter/Service Leak: Classify - City: Cush: __
A.Water toss (Esim.te:: GPM ?ire plug flushing ___ __ Total Gallons
S.Was Water Metered: Yes __ No
C. Was Customer Notified: Verbally _ DoOwiOCB3:R
Vehicle/Equipment Used 4
3.If Meter Change Out: Unit 0 Miles Hrs quip
A. Old Meters [ /& 1 34 Reading/ ■ b
'r I
3. New Meters ,25/2- �� 7 Reading f)
C.Old Meter
S ` t y 44 - .." . ----12:-Now Meier Size /Type A4POW‘ , r- -.6f\. • -
R.Dype of work performed or findings:
JO '' zti e4 /44 / 6 c-c,
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 .1lanhours : , 1 Craw members
II.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities sster inspection: pass or fail •
14.How many trips to do tank? C�-� '
Signature