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WATER
Issued: 44 D2 Finished: `I'!d - d't_ Employee: MVP, (s A y P Grid Map:
Name: Ria. f1 Address: 420 clime/hill Der.
Phone Number (HM): 312- 462 -'7619 cwK-
Check For: Accuracy Test Meter Leak Post -it® Fax Note 7671 Date 9 of
_ 4'27' �2 Ipa# g es
Initial Meter Relocation Inspections To K ali J IUD hri bn From Delit 'Avalon 2. Repair 3. Co. /Dept. all Co. i r. RK t-
1. Backflow Insp. Phone # -(1 J
Phone #
Backflow Insp. A. Main Line A. Fax # Fax #
Bkflow Cert. Date B. Valves B.
Re -Cert. Date C. Service Line C.
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 Lela EST FOR SERVICES: *lard Sirtet M3492. ? ReC kaki( y 010a-
'4 P l-, i.fo, der, on. L(ZD , q , Ls- a -cress k4 , -
LaV' ai 44,; +rrolp?,`ax wet4 trot 0/1., /'.
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 R q 0 P - `� ' y Reading 1 a e i 05-
B. New Meter 7 2 (4 E 1 2. 4i Reading
C. Old Meter Size / Type Prcta 3. o/t. r kiX 3 /4 New Meter Size / Type a 44 std, '4 K 3 /9
E. Type of work performed or findings:
9. If mainline or deep service repa . describe type of pipe or service line and condition:
10. Man hours: /•- v Crew members: LA-kr C,
1 1. List materials used: I (i / ? ! , '2 1 �►r �° _ �, /.'` /Za� t 1 q i1 P;t•�'�y C t
2' iJ&i" l' oev / 3f �1' eh 4P / sA, „ e iv', il' L' A44,/ l e, 7ee'VV
`-/ y424`$ 4Ac4 P'7 /1 L yArt4.
12. [f you had an accident/incident :rile performing this request, did you report it? YES or
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? 1 1-
Signature