2000_0218 WATER
Issued: Finished: `Z "-/ �-'" Employee: / 6 (c ci, Grid map:
Name: Address: 52. ct r� » 1 _, o- -> t.
Phone Number: (HM) (WK):
Check for Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. B 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: 41E -tN12 C IP t.J y e 0 ce
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 4 ss 74/364 ij Reading 13.E // 5 .-C 6 U / f 0
B. New Meter :,1, to y / 6 3 Reading
Old Meter Size/Type: S A - t »c p A D New Meter SizeiType /7)/45/0( 5 2
E. Type of work performed or findiffgs:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: �� ? , N � - Crew Members. /
11. List Materials Cased:
12. If you had an a : : :denCLzcident 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 /1/ / (/ y^)