2000_0302 WATER
Issued: Finished:�� Employee: meif-,0 Grid map:
Name: Address: 1/1 /�` le5 e� - �e woe A
Phone Number: (I-Dv() (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
Bk flow Cep 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: !%-1 e e.. G N , 1� cE - r -
7. If MeteriService 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
3. If Meter Change Out: Unit *Miles Hrs Equipment
A. Old Meter #• 30 3 5 Reading _4 c-qb/
B. New Meter 7 (0 Reading
C. Old Meter Size.T• 5 /is /j 4 . J D New Meter Size/Type /fj �� ' ffe
E. Type of work performed or findin -
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. ,, -�_.. )6_ 445 Crew Mer...ers.
11. List Nfa:eriais Used:
1?. if :au 3d i : iccide. ^,c'-c :dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: Cc?) or fail
14. How many trips to do :ask?
Signature iii
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