2000_0228 WATER /
Issued: Finished:• <) ' Employee: 14'� ', C Grid map:
Name: Address: V 1
Phone Number: (I 1M) (WIC):
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
Bkrlow 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: fki e / K (f 1 (ti, �j�? 0 (14--
7. If Meter, Service Leak: Classify: - City: Customer
A. W ater Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
3. If Meter Change Out: Unit T Miles Hr Equipment
A. Old Meter 9'Y 57 Reading ? L� �f 0
B. New Meter # 1 Reading �?
C. Old Meter SizeT 5/g itti/q r. �( D New Meter Size(Type ✓/
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man --c- .. /-2 � i Crew Members.
11. List Ma:e-:als Used:
12. If you had an accident L:cadent while performing this request. Did you repar, it? Yes or no
13. Water Utilities meter inspection: s or fail
14. How ;..any trips to do ask? ^t
, Signature
1