2000_0218 WATER
Issued: Finished: 2-- /8- Employee: ! ► ig C Grid map:
Name: Address: 30 9 (' l e a.AD r(,!V A
Phone Number: (FAA) (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
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: C E' r C :L►tif t!O d (1
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
8. If Meter Change Out: r,, Unit # Miles Hrs Equipment
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A. Old Meter # e$ r "o_� Y Reading < 2-0 5 S /1 5 ��� ( 0
B. New Meter # 7 . (c Y 1( ( e. Z Reading
C. Old Meter Size/Type: 5/R 73j pv' New Meter Size/Type - /, /f3- le.
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: K2:, Crew Members.
11. List Materials Used:
12. If you had an : ::dent'Zncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pas or fail
14. How rnariy thps to do task? /
Signature'h ,�
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