2000_0302 2 WATER /� ,(
Issued: Finished: ` �, C-2 Employee: il )-,GC L' Grid map:
Name: Address: 41 I (c N:i 4) P_,i, .t
Phone Number. (FD,I) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackilow trio. 2. Repair 3. Maintenance 4. Other
Backflow Lnsp. A. Main Line A. Pump A. Line Locate
Below Cr. e Dare B. Valves B. Water Tower B. Line Locate
Re-Cert. Dare C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
5. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: m.L- f " E ) ►k e 0 it t"
o
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (esdW ate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Mete: Cage Out: r (J Unit 4 Miles Hrs Equipment
A. Old Meter .. Ti 7 5 5'4:10 Reading I c� 1 1 7 , 4r6 d 11
B. New Meter * .CoLj/ -. I Reading i
C. Old Meter Size.Type :4/c 6)4 ri F t D New Meter SizelType 5/ //,f/$ f < >"
E. Type of work performed or findinis:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
I � Crew Me...Ilers.
11. List Ma:e::als Used:
1?. If you : : ^ad 1:1 accident L-c:dent while performing this request. D :d you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many Ti ps to do ask?
Signature /, l'