2000_0221 WATER
Issued: Finished: ?N Employee: /11 Grid map:
Name: Address:5 ,5 3 a. ce&vo
Phone Number: (KM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Jteoair 3. Maintenance 4. Qtha
Backflow Insp. A. Main Line A. Pump • A. Line Locate
Bkflow 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: /e lLe YL J c rt/t12 Q eL &
7. If MeteriService Leak: Classify: - City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter /4/ Reading 1 C O. 1 / 5 i (TO
B. New Meter # 6 L/ 30 t7 Reading
C. Old Meter Size/Type: f,e e j SI n Yv 5 7 D New Meter Size/Type /'j/15/ s/g
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 - hours: /. Crew Members.
11. List Materials Used:
12. [f you had an accident ncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: ass or fail
14. How many trips to do task?
Signature
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