2000_0302 (2) WATER
Issued: Finished:. 3° -2 -.0-e Employee: MC /�Lr� r�} Grid map:
Name: Address: I , /
c1 ! i e c f1- v-J (/ i c i <<.)
Phone Number: (I-04) (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 Insp. A. Main Line A. Pump A. Line Locate
Bkrlow Cr. e Date B. Valves B. Water Tower B. Line Locate
Re -Cer. 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: ' J cx i Div M& e (i hail)? P G%Lf
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (esrarate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Mete: Change Out: Unit # Miles Hrs Equipment
A. Old Meter # 1171 (C 7 (7 Reading 6 IS I 0 rl 7 •%O
B. New Meter # % y 4 18 y Reading
C. Old Meter Size-Type: ('� Dew Meter SizeiType 1' / E., F iZ
E. Type of work performed or findl'ngs: 0 i�,lq i ti ��t?i f 1 i OD
n a cp 1 r � cU
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. 4 1, 0-1 Crew Members. 1
11. List N(a:erais Cased:
13. [f you ad in accident, ::.c:dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: /pa#s or fail
14. How tr.nay trips to do :ask?
Signature /�l