2000_0210 n WATER
Issued: 0 Finished: c /( Employee: �1�"f/ Grid map:
Name: Address: 6
Phone Number: (HM) (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. ,Lfain Line A. Pump A. Line Locate
Bkrlow Cert. Date B. Valves B. Water Tower B. Litre 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:
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
3. If Meter Change Out: Unit 4 Miles Hrs Equipment
_ --C4 'cteter.4 , S (v Reading /I13 /1/
B. New Meter 4 Jan 0 # Reading ows.'9
C. Old Meter SizuType :f ren it,n /fX 3AL D New Meter Size/Type iV10 54- x 3 /�y
E. Type of work perforad or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
:0. `.Ian- hour3: Crew Members.
11. List Materials Used:
12. If you had an accidentIncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
1
Signature
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