2007_0328 WATER
Issued: 31 g' 07 Finished: Employee: fr L �; Grid Map:
Name: Address: 232 GJ, ou/ 5- ri vt,/s
Phone Number (I-Dl: (WK
Check For: Acc. racy. Test Meter Leak Check Water Pressure
Initial Meter Relcc_ :;on Inspections Re -Read
1. Backflow Ipso. ' Repair 3. Maintenance 4. Other
Backflow Inso. A. Main Line A. Pump A. Lire Locate
Bkflow Cert. Date 3. 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 DOORK`OCKER
3. If Meter Chanze O.: ::
A. Old Meter = 2 g 33 i9q Reading 3
B. New Meter = c57 Reading.
C. Old Meter Size /Tye New Meter Size / Type
E. Type of work perfcrrned cr - ridings: 1d1 -'ur C . OA , I.. 4.4. or.
Cu5 +0hoc 5t, V :L€ (;out . .F(o& C &Jer S t/till 0
CIL Cd.er1 ioC4{.S .
9 V ,..,.,dine _r �' ee:._. :t:1.7. describe type of pipe or service line and c ::.dition:
l0. Nlan hours: 1 S Crew members: Fret, I • Ti.f-f B . .
l 1. List maceriais use' CA /t ilc-c
l ft ' 'nad an acci(_!en. :;;ciders : :.;hile •er arming this request. did y9u report it? YES c r 'CO
13. Water Ltd itie:meter inspecticr PAS or FAIL
14. i{ow many trips to 'o task? 1 3.'i 7...
Si°nat.re