2001_1106 ►l
WATER
Issued:/ Finished: / 6 F.mpfoyec: � ` `^ -� , I C.:d
Name: %I . -t . 1- .1 r • , Address: • i 0 1— 10.) 2.8
Phone Nurnber. (F'LM) �/� r
Check for. Meuracy test. Meter Laic: Check water pressure:
Initial meter relocation ripeedoes Re -read
1. Backflow asp, 2- jtepait 3. Maintenance 4. Qsker
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dace 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. Safe' y
S. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment u site if applicable:..
A. Barricades B. Cones C. Tape D. Lights E. Other
u est r Services y g, •I • a . • MI • A-
7. If Nfe : - r: Se rice Leak: Ciss_, - City: Cus :or_er
A. Water Lou (esti ::): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified.: Verbally Doorknocker
Vehicle/Equipment Used
8. If M ::er C:.a g: Out: Unit : Mies Firs Equipment
A. Old Meer 4 / Reading ! 7. f
B. `ex Meter s - iS Re • • g 40
C. Old Meter Sizes t ype: 4 +9P1, _ • New Meter Size/Type 02- - v
E. Type of work r pm orWed or • dings:
9. If mainline or deep ervice r.air d cribe type of • ipe or service line d condi . o •
11' FRRIMUMMIIIMPTOOMMTEIMMARPOTAr
10. Man-hours: J . g --""
Crew Members. /1/7,
1 1. List Materials Used:
•
12. If you s- u_ :deza ?arC :�t while performing this request. Did you reper.:;' Yes or no
13. Wiser Laltaes meter it:spe :den: pus or fir: •
14. How many zips to do ask?
Signature