2000_0214 WATER
Issued: Finished: 9- - /'-/_(/-0 Employee: In ',0, Grid map:
Name: Address: / C l me 0. &c}- -r /Ark
Phone Number: (KM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read C) 2
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backlow Insp. A. Main Line A. Pump A. Line Locate
Bklow Cert 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: /V 4 Yh o -fed' e h . c\vl (') Cd of (4u,`t e 0,L)
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7. If Meter/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
8. If Meter Change Out: Unit 4 Miles Hrs Equip ment
A. Old Meter T T670 gO75 Reading bo2 Z " . 2 R o/
3. New Meter = .24n 3 2,34 Reading 02
C. Old Meter Size.Type: D New Meter Size/Type 576 ,7 e,, rr
E. Type of work performed or findings:
9. If rrainline or deep service repair, describe type of pipe or service line and condition:
10 � 2- 4111t Crew .Merr:cers.
11. Lis: Ma:erials Used:
12. if :cu had in accident. :..:dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How rr.aay trips to do ask.?
Signature