2000_0302 WATER
Issued: Finished: ^ `�� l.;
°' Employee: �� l/w Grid tnap:
Name: Address: IOS JYj es I cc,2*7f
Phone Nt r ±er: (HM) (WK)
Check for: . :curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. }tepair. 3. Maintenance 4. Other
Backflow Lisp. 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: n) ,4ee. e kti F G +'.Lt
7. If Meter. Service Leak: Classify: - City: Customer
A. W ater Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment used
3. If Nfete: Change Out: unit T Miles Hrs Equipment
A. C d Meter .4 y 3e e! 13 y Reading 2- 131-4 Zc 7 tl
B. New Meter 4 L 9 0,6 .L Reading
C. Old Meter Size. yoe: ( 4A r € te D New Meter Size/Type ,/‘,
E. Type of work performed or finding:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. M a-- . - =_:.
1 Crew Nfer.. :e:s.
11. List Ma: :::als Used:
1 [f y cu ?:ad 1 1 accidenC _.::dent while performing this request. Did you re;or. it? Yes or no
13. Water Utilities meter inspection: 4p�ss or fail
14. How .:any trips to do ask? 1
Signature ✓ J2 /