2000_0302 WATER
Issued: Finished: 3 - Cr0 Employee: n.- 1 Grid trap: 11
Name: Address: f 1 MC' S Ci. U 1fe wo�'D'
Phone Number: (1-D,1) (WK): V
Check for: Azcuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backrlow Insp. 2. Repair -3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkrlow Cer Date B. Valves B,-Water Tower B. Line Locate
Re -Cer_ 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: / Y f P . / I c h & iv e t,e
7. If MeterService Leak: Classify: - City: Customer
A. W ater Loss (est nate): GPM Fire plig flushing Total Gallons
B. Was Water Metered: Yes No C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment used
3. If Meter Caange Out: Unit 4 Miles Hrs Equipment
A. O d Meter 4 (p036761 Reading 2-0137 / / 7 o7S6// O
B. New Meter 4 (o i-/ I (P 2,4 Reading 0
C. Old Meter Size. Type: 5/ ' f31/ ` E' D New Meter SizeiType 57? y'✓l i�SfEe
E. Type of work performed or fin i s:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma ..._.. / Crew Nte,..cers.
11. Lis: Ma:c ^as Used:
1?. If ca 'ate an aczident :dent while performing this request. Did you report it? Yes or no
13. Water Utilities teeter inspection:
Cass or fail
14. How .:any sips to do ask?
Signature 1r/ key'