0000_0429 WATER
Issued: " Finished: 4 Employee: lLlM -5 /; Grid Map: _-'_--
Name: Address: o 40,0 d/y o o 4
Phone Number (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &Hit 3. Mitanain 4. C tie
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: / *fe e, I
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 : 02, 7 - S Reading ) 715/
B. New Meter T oZ-f/ ?-q6 2 — ,o Reading
C. Old Meter Size / Type a'8 x / f 'ACk'a4✓ New Meter Size / Type "/ L X 4 "I 4 f 7
E. Type of work performed or findings: /7 /EP o [7Z > a l rS RD /(' /
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9. (C mainline or deep service repa::. describe type of pipe or service line and condition:
10. ,Man hours: Crew members:
11. List materials used: / /Y- e,L — 3 /`i .r.�ee
12. (t you had an accident/incident •guile performing this request, did you repot it? YES or NO
l 3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
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