2001_0215 WATE •
�f Finished 4r ivL
LIssued: I Employee: Grid trap:
Name: (, 43 c P-A- A• • • • _5 /1 _ - .
Phone Number. (FLT!) (WK): e/ 7 - !p y0 _ 3 7 7,X
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow 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 X a.L 4/2A UAL (pp t, Ajr
1
7. If Meter:Ser ice 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 # Reading
B. New Meter # Reading
C. Old Meter Size/Type: D New Meter Sizerfype
E. Type of work performed or findings:
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:
1 ec a,. �5 C u� j '®wi ey5 S: ele_ <
12. If you had an accident/Incident 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?
Signature /