2000_0214 WATER
Issued: Finished: P.-- ��- 4 mp1oyee: 0 i �, /N L Grid map: 11
Name: address: 1/ pi er,4, a I P/,) i >>
Phone Number (FDA) (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
Bkcflow Ctn. 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: a- e C-V (\ N l� G O a t'
7. If Meter /Service Leak: Classify: - City: Customer
A. Water Loss (escalate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment Used
8. If Meter Change Out: Unit 7 Miles Hrs Equipment
A. Old Meter 4 1q 4S Reading 163 0 1/ S � 6
B. New Meter .2 Reading
C. Old Meter Size.Type: r4 f. r D New Meter Size/Type-C/4 filit5tt,e
E. Type of work performed or finding.
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. / Z-- Crew Me...7e75.
11. List M3:e-ials Used:
12. If you had an 3ccidenu :-.cident while performing this request. Did you reper. ;t? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How r .any trips to do ask ?.
Signature `6 �. / '