2001_0221 WATER
Issued: Finished:2'2• 1 Employee: /W( (1 d Grid map:
Name: Address: 461 /?ie ' UL'
Phone Number: (FDI) (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
-
Request for Services: Me 4e if L'- h a yVg-e. l "J U 4-
7. If Meter /Service 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 Change Out: Unit # Miles Hrs Equipment
A. Old Meter # 7'/ 2S.9 Reading 10 11 S 2(o
B. New Meter # ;1_6 y3 0 Reading
C. Old Meter SizelType: 4 Q� . D New Meter Size/Type/J/45-0T 5 7e
E. Type of work performed o endings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: 7 Crew Members.
11. List Materials Used:
12. If you had an a.:identiIncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
C.
14. How many trips co do task? /
Signature , ,/ / /� �j