2000_0214 WATER
Issued: Finished: f J % "" Employee: 49(r/ Grid map: (,
Var e:
Address: 70 7 OP. i4 AokAiG,64 ?1\
Phone Number. (I-N) (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 Lisp. A. Main Line A. Pump A. Line Locate
Bk21ow 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: /4e'7 e h ar N 00--
7. If MeterService Leak: Classify: - City: Customer
A. Water Loss (esrinate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclelEquipment Used
8. If Meter Ceange Out: Unit T Miles Hrs Equipment
A. Old Meter r � (o 63 2 j ? Reading 30:7/6 / f (qo
3. Yew Meter T (o Reading
C. Old Meter Size-Type: 55A 8 New Meter Size/Type /jj
E. Type of work performed or findin :
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ala . _: Crew Me: - .7ers.
11. List Nta:er:ais Used:
1?. [f' %oL "ad an accident.. while perfcr:ning this request. Did you repot, it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How r.any trips to do :ask.?
Signature j i" /