2000_0216 WATER
Issued: Finished: Employee:,' 2 / ;» Grid map:
Name: Address: ..,(1))
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow [nip. 2. Repair 3. Maintenance 4. Other
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: le-/Q, C L, (,.
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 -
VehiclefEquipment used
8. If Meter Change Out: unit # Miles Hrs Equipment
1 f755� (2d Reading 4 S /� r c 6; 61(16
A. Old Meter , � u ;
B. New Meter # 2 li 5/1 2_ Reading CD
C. Old Meter Size/ Type: D New Meter Size/Type
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: lL Crew Members.
11. List Materials Used:
12. If you had an 2::_identIncident while performing this request. Did you report it? Yes or no
13. Water Utilities rr.eter inspection: pass or fail
14. How many trips to do task?
Signature c t)' ° -. //I)