2000_0228 WATER
Issued: Finished: '7 ' Ut Employee: A'C` t.:kti Grid map:
Name: e: Address: o -c X7 plea 60 W tJf C4 .1,/ K.,
Phone Number. (1F0,1) (WK):
Check for:.A:curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Lzsp. A. Main Line A. Pump A. Line Locate
Bkflow Ctn. 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: inei4 r )t a Pi 6'u'
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 -
VehicleEquipment Used
3. If Meter Change Out: Unit 4 Miles Hrs Equipment '
A. ad Meter 4 a' 6 yiV l 3 Reading V0265 ) i 7 6 0 1C 7e )
B. New tifeter 4 74 q/'i3 Reading
C. Old Meter Size : ype: 5l/ $-, •� -,t_ D New Meter SizeiType
E. Type of work performed or fm ii , gs:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma::- ::c_.. 7 Crew Me... :ers. i
11. List Materials Used:
13. If you : ^.a. a:: accident:-.::dent while performing this request. Did your por.:;? Yes or no
13. Water Utilities meter inspection: pas or fail
14. How ,:.any trips to do task? J
Signature �1d1;"*k_