2000_0214 WATER
Issued: Finished: Employee: /lie/ Grid map:
Name: AddreSS:'•- 7 /We G.)‘C
k
Phone Number: (HM) (WK): _
Check for: .Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backrlow Insp. 2. Repair 3. Maintenance 4. Other,
Backflow Lisp. A. Main Line A. Pump A. Line Locate
B:cflow 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: 14t i < ( /J. ✓'v t✓ (7).
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 = Reading ) C 5a
B. New Meter 4 Reading
C. Old Meter Size.Type: D New Meter Size:Type
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. `lay- ..___: c`- ¢��� Crew Menthers.
11. List Materials Used:
12. If you had an acciden ..: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 ask?
Signature `\ ? 7;�