2000_0306 WATER
Issued: Finished: 3` 6- e?) Employee: C /L O £ Grid map:
Name: Address: / 1 !Vies a U
Phone Number: (I-LNI) (WK):
Check for: A:curacy 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
Bktlow Cr. e 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: /le4e X. 0. c ) 7 0 (,/l
7. If Meter ;Service Leak: Classify: - City: Customer
A. water Loss (emmate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment used
3. If Meter Change Out: y Unit ; Miles Hrs Equipment q V
ipment �l
A. Old Meter . a / 3O /7 Reading l / 3'/ v2 nl�j 1/ 7 O / I
B. New Meter T 4 L /) 4, ( 2 Rea g
C. Old Meter Size.Troe: r3/ad pro D New Meter SizeiType 5/ 477!4 Sf
E. Type of work performed or figs:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
V). 3 /L Crew MIern : :ers.
11. List N(a:erials Used:
1?. [f you had an accident ::dent while performing this request. Did you repo it? Yes or no
13. Water Utilities meter inspection: ass or fail
14. How .:any tips to do ask'
Signature