2000_0228 WATER
Issued: Finished: Employee: fZ,���� Grid map:
Name: Address:
Phone Nur..cer• (1-DA) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re - read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Lrtsp. A. Main Line A. Pump - A. Line Locate
Bkflow Cer Date B. Valves B. Water Tower B. Line Locate
Re -Cer-_ Daze 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: /Ile-le rJ e ( / (
7. If Meter; Service Leak: Classify: - City: Customer
A. W ater Loss (estivate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclelEquipment used
3. E: Mete: Caange Out: Unit 4 Miles Hrs (`S Equipmen
A Old Meter 4 �� z ! .�y Reading S 76/ 7 .� (, /7 d
B. New Meter 4 IL ) Reading ,&"
C. Old Meter Size:_ne: 2 't /3 /)t9 D New Meter SizeType3/i' /17,�JS
E. Type of work performed or findings :
9. If mainline or deep service repair, describe type of pipe or service line and condition:
i•). �•Ia / /4 � Crew Mer :.�ers.
11. List Mater :a:5 Used:
1?. lf; cu a accident .-::dent while performing this request. Did you reper. it? Yes or no
13. Water Utilities meter inspection: or fail
14. How . :any nips to do ask.?
Signature