2000_0228 •
WATER ,�((
Issued: Finished: .2. aq' c "C 7 Employee: 0/1.-4.9 C Grid map:
Name: Address: C'O I eCID0 u) UJ'e.W 6 t 1
Phone Number: (FL M) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Ce- Date B. Valves B. Water Tower B. Line Locate
Re -Cerr. 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: Inc4e h ■ +A id, e-
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (esrmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehicleiEquipment Used
3. If Meer Change Out: Unit T Miles Hrs Equipment
A. Old Merer.4 VD Reading 31532 ( _ 7 ." rid
B. New Meter T 1- (o LI l I C Reading 0
C. Old Meter Size.Type: - 5l � p( D New Meter SizeiType/i/4 -57g" E. Type of work performed or finding
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. aa -`:c _ -. I S Crew Nter..1ers.
11. List Ma:e-ais Used:
13. [f you ^ad as ic.ident'.:c:dent while performing this request. D:d you report it? Yes or no
13. Water Utilities meter irspection: pass or fail
14. How many trips to do ask?
Signature