2000_0215 ,.
WATER
Issued. Finished: Employee: J '{i /e6 Grid map:
Name: Address: 7 3 , 2 - J2 (k c (ILA) C_A r 1.
Phone Number: (1•1vi) (WK): —
Check for:.A:curacy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow 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: 77/6-'77, e' C. Vl c x yjp _
7. If MeteriService 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 Equipment
A. Old Meter 4 6 6 0$6 68 I Reading /7565 j / 5 ,2 &c/ U
B. New Meter T ;260 Reading
C. Old Meter Size-Type: 5A 6/41 D New Meter Size:Type 5/{' /705-frIC
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ala- Crew Nfe...oers.
11. List Ma:eriais Used:
P. [f y oc ::ad an ac:ident ...cident 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? 7/:e41.1- s s
Signature (3/