2000_0218 WATER
Issued: Finished: Employee: ' /5 C e Grid f map:
Name: Address: 75 G ill e M (4c, ,-' ' L? (3.
Phone Number: (I-0.1) (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: /o5 - -/ - (? 01 7 04E%i' C')
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 # g3 5 it—.. Reading /1 7 � YC`
B. New Meter #, t y 14 ,'9— Reading
C. Old Meter Size/Type: 5" f> a +',' D New Meter SizeiType5/ ' )1// f` ►�
E. Type of work performed or fmdizs:
9. If mainline or deep service repair, describe type of pipe or service line and condition
10. Man- hours: )',Z Nom Crew Members. r
11. List Materials Used:
12. If you had an a: identIncident 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?
Signature ' `