2000_0228 WATER
Issued: Finished: "vim Employee: / {Y% <;' Grid map:
Name: Address: (i." _? 9 61, :ti
Phone N;:Tcer: (Dv!) (WK):
Check for: A :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Back flow Lisp. A. Main Line A. Pump A. Line Locate
B k iow Cr. e Date B. Valves B. Water Tower B. Line Locate
Re-Cert. Da :e 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: J'YA � _ (' � {`� f L1! j'
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (esnn ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Me :er Mange Out: Unit T Miles Hrs Equipment
A. C :: Meter y.5 77?) Reading /2 1/ 7
B. New Meter .4 G z// Y / ReadingAISIN
C. Old Meter Size.T e - D New Meter SizeiType /f — /1j/}57 ✓�
E. Type of work per or fin• . •Ks:
9. If rnainlir.e or deep service repair, describe type of pipe or service line and condition:
10. `•L- .. :_: �� Crew
11. Lis: N[a :c::ais Used:
12. If .L as ac ::dentL.c:dent while performing this request. Did you report t ?? Yes or no
13. Water Utilities meter inspection: 6s1) or fail
14. How many trips to do :ask?
• IT
S;grtature ` � v.