2000_0214 WATER
Issued: Finished: a -/4 —c5-0 Employee: Z Grid map:
Name: Address: 7/,5 Me'rr c t c' k
Phone Number: (KM) (WIC):
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 Lisp. A. Main Line A. Pump A. Line Locate
Bk_flow Cert. Dare B. Valves B. Water Tower B. Line Locate
Re-Cert. Daze 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: C h ri /g e
7. If Meteu'Service 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: L'nit T Miles Hrs Equipment
A.0'.d Meter # ' 75 ' , 2 5.'- Reading D-731 1i 5 a S( cot) )CjD
B. New Meter T 3d4 1 c)(N Reading
C. Old Meter Size :Type: (Z, �/� D New Meter Size/Type J,4419 } - e r .57c
E. Type of work performed or t1 dings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
Crew M°r ±ers.
11. List Ma:ettais Used:
1?. If you had an a ccident':.::dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How .:any trips to do ask?
Signature