2000_0218 WATER
Issued: Finished: ,? _ Y - 1 Employee: /' jiVf_s ; Grid map:
Name: Address: 3 I 1 1 Ii eA (1; - ct
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow 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: e '/ � 1 ci. r� � (it
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: Unit # Miles Hrs Equipment
A. old Meter 4j 5 ' Reading / )_3 ZS 1� ' - 9
B. New Meter # 2 "// (< 5 l Reading (C1
C. Old Meter Size/Type: -5/<<, /3/.7 D New Meter SizeiType %
E. Type of work performed or fording
9. If mainline or deep service repair, describe type of pipe or service line and condition:
/
10. Man- hours: / 1 Crew Members. /
11. List Materials Used:
12. If you had an icziderailncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: ,paste or fail
14. How many trips to do task?
7 ''
Signature /1 _ 1 /