2000_0226 WATER
Issued: Finished: a'oC .- 0-73 Employee: 4/K. Grid map:
Vie LAJ
Name: Address: 5 'SO m e4l &OLU
Phone Number. (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Dackflow 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: m e /er e ) i,. Ile, 00 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 # , 9 I 3 Reading /609 9 // 5 (3,f60/
B. New Meter # Reading t
C. Old Meter Size/Type: 78e.15/o S/ D New Meter SizeiType /11iA HP S erif
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: "2 t /r� Crew Members.
11. List Materials Used:
13. [f you had an accidenclncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: { / _ pang or fail
14. How many trips to do task? �y Nom/
Signature 7f /,! e/1-471