2000_0421 WATER
Issued: Finished: Employee: MC- / E-o C r ' / Grid map:
Name: Address: �* i 1� / P_ a 6 ou) UI-e L. t.)
Phone Number: (1-LM) (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: Ne_vti h e �'� a re. - FP 0. 6
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 i �577fa Reading 11J0. real') it 5 k) /9d
B. New Meter # 2 .fo'�( e I ReadingOOC q 3 �/
C. Old Meter Size/type: D New Meter Sizeitype 7' J4'b1 Sf
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
W. Man- hours: /L 14j1-- Crew Members.
11. List Materials Used:
YVONe
12. If you had an accidentilncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: (as) or fail
14. How many nips to do task?
Signature V, « /�