2000_0221 WATER
Issued: Finished: a ' 6*-C/ Employee: in C �� G ( Grid map:
Name: Address: 6/ Mea. 6 0 tv j/l e 141
Phone Number: (HM) (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: ei iE i e_
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 # '92S6 7a Reading 33a 5 1/ 5 ,25601
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B. New Meter # 17 Reading
C. Old Meter Size/Type: n / i c e K_ New Meter SizeiType 17 • - e '
E. Type of work performed or fins . gs:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
1 /
10. Man- hours: Crew Members.
11. List Materials Used:
I2. If you had an accident'Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pas0 or fail
14. How many trips to do task?
Signature. /Y1 (9/�