2002_0701 •
WAFER //
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Issued: 7 --/ �D Z Finished: 7 - Z- Employee:��'// e, �l // b Grid map:
Name: Address: / Z 3 M Xcai
Phone Number (FLM) (WK):
Check for: Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackf1ow Insp. 2. Repair 3. Maintenance 4. Qtbi
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
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6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services:
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 # Miles Hrs Equipment
A. Old Meter 7
� / / Cp Z.5 VVa/ Reading d c
B. New Meter 4 '3/510?I' S F ending j! s
C. Old Meter SizeiType: 4 f /1 D New Meter Sizetyype
E. Type of work performed or findings: ,'Y /flCe 6 ,J Joe
/1 /G' o
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew Members.
11. List Materials Used: /-toc / yeJ 4° /.lr „/i &
12. If you had an accidentlncident 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 ' /WA')