2000_0210 r,raxdr�3 . i
WATER
Issued:0 0 Lo Finished: O Employer. (),4 Grid map:
tiA____ Name: Address: C, I
Phone Number: (HM) (WK):
Check for: A curacy 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
Bkiiow 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:
7. If Meter /Service 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
A. Old Meter 7 • . S 6 o'7 Reading ..3 ,
B. New Meter 4 , I Rea ing St 4f7f) D I
C. Old Meter Size:Type: Pr , 41 A X D New Meter SizerType�S}C� t
E. Type of work performed or findings: �
9. If mainline or deep service repair, describe type of pipe or service line and condition:
:0. Man-he.:: s: Crew Members. //— /
11. List Materials Used:
12. If you had an accidentL while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do task?
i . .
Signature r / "