2000_0818 WATER
Issued O ;ter Finished Employee k A ('� _ Grid map
Name: Address: •
?hone Number: (HM): -- (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak:_ Check water pressure:_ Initial meter relocation inspection Re _
1.Backflow Insp. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
E. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
;.If Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Estimate:: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: Verbally DOORIaIOCXER
Vehicle /Equipment Used
o.If Meter Change Out: Unit
!� Un 1 Miles Hrs Equip
A. Old Meter# a L / 6V�� Reading�� l/�d
� �7 I, ) h� l p I
3. New Met ert2 14 4 3'P Reading � '" / i �c rf _r l'�1 'e 't e C �S
C.Old Meter Size /Type: D. New Meter Size /Type
(.Type of work performed or findings: elpeAn5e4 YVT fl
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: lid, Crew members: e ! ,
1I.Liat Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yea or no
13.Watsr Utilities meter inspection: pass or fail
14.How many trips to do task?
Signature