2001_0919 • 1 WATER jo
Issued: �iai s lyed; Employee: Grid
Name: Address:
Phone Number. (Fib!)
Check for. Accuracy test. Meter Leak: Check water pressure:
Initial meter relocation inspe :does Re -read
1. Backtlow last'. 2. &ask 3. Maintenance 4. Om
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Dace C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reuoa for failure: A. EElectrolysis 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:
1
7. If Meer: Service Leak: CCas;_; : - City: Customer
A. Water Lou (estitnace): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Nodded: Verbally Doorlmocker -
VehiclelEquipment Used
8. If Meer Cr azge Out: Unit # Miles Hrs Equipment
A. Old Meter 4 03 Reading o 8
B. New Meter 4 ' Reading C
C. Old Meter SizerT;ype: .3 t tezet. D New Meter Sizefr .
E. Type of work perforWed o findings: y /4S 1e-e ,97£ d AlO
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Mar- hours: 1 Crew Members.
1 I. List Materials Used:
12. If you had r accide:ca ?-::d :car while performing this request. Did you repor.:t? Yes or no
13. Wirer Uahaes meter iaspec:an: pus or fail
14. How many trips to dotask?
Signature a L