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2002_0619 WATER Issued: Co ^ r' of inished: Employee: R./1/N Grid map: Name: Address: k0 C a OE, 1, Za Phone Number: (HM) (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 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: 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 0 8. If Meter Change Out: Unit # Miles Hrs Equipment A. Old Meter # 1 a a \ Iv 5 3 Reading 51+ a 4-S B. New Meter # a1/4)4 14 1i Ca Reading C. Old Meter Size/Type: ()q e D New Meter Size/Type (A G s ( 3 E. Type of work performed or figs: C 41■5e.d ov ©\,a Me r ne o Q. 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: 12. If you had an accident/Incident while performing this request. Did you report it? Yes or no �y 13. Water Utilities meter inspection: pass or fail 14. How many trips to do task? Signature --".„11,