0000_0920 aai,ek \ 1 1
WATER '�
Issued: 9 / 2 U Fiinishe& Employee: // ` Grid Map:
Name: i k1 . 1 /� v1 Q_ a,, .G? Address: liar) a/ C
Phone Number (HM): (WK :tX , -/V - 0 S/Z 59 7 -T
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: / , --ea - IiC,G:;?—z-c-- , ,/
1
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
8. If Meter Change Out:
A. Old Meter = 2 4/ 414 2 Reading 0 0 30 /q
B. New Meter .. 2 3 2 C 1 s(• Reading 4
C. Old Meter Size 1 Type ,Ws ru- c— � x 7l� New Meter Size / Type yuiesG ie ''/ ' 14'
E. Type of work performed or Endings: 01 -& e � ,e— G9
9. [(mainline or deep service repa::, describe type of pipe or service line and condition:
10. Man hours: • ' Crew members: /
1 1. List materials used: Attee --1.-0.6 A%c1<di
Post - it® Fax Note 7671 Date q4 I p# s ■ a 1
12. l [ you had an acc :denu mcide ^.t x hil - . . • ing this rec To Key "��S�ti From t (
Co. /Dept. w -BILLtsv Co. lATI LIT( E5
l3. Water Utilities meter inspection: PASS or F Phone # Phone #
14. Efow many trips to do task? 1 / 'R Fax# Fax#