2000_0215 WATER
Issued: Finished:c — 1 Employee: /1:7�s-e-7 CD/ Grid map:
Name: Address: 731 mg:a AOU} L GU /c
Phone Numcer: (I-LM) (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 Insp. A. Main Line A. Pump A. Line Locate
Bkilow 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 f o r Services: MP 4-e( C h A iRr e t r
7. If Meter /Service Leak: Classify: - City: Customer
A. W ater 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 Equipment
A. Old Meter # ��30 II() Reading / ,? v 5 02f 6of �O
B. New Meter 4 2 co I) 1-( Ss Reading
C. Old Meter Size. yne: /1 P r 57.< New Meter Size/Type 5 / - m,S4eQ
E. Type of work performed or dings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
45 t
10. Nfa^- ::c. - . /
_ Crew Me... :ers. /
11. List Materials Used:
1?. If you had an accident' ::dent while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?
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Signature . ;�,