2000_1101 A/ e, LA- c,--7"-e r
WATER
Issued: 1 1 ( (00 Finished: Employee: G Grid map:
Name: 11) 6 - Eci Address: O till .4 .ti t /
Phone Number. (F') (WK):
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 Cat 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. Ni asw Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
1 I A. Barricades B. Cones C. Tape D. Lights E Other
Request for Service N I l 0� l 1 aiJ i L , .Oi CA A Alt
17) 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 Doorlmocker -
Vehicle/Equipment Used
8. If Meter Change Out Unit 4 Miles Hrs Equipment
A. Old Meter * q 7..2 a - `I Reading 2. 227/
B. New Meter 4 & Reading -E_—
C. Old Meter SizeType: -s A 1 O /idea o., D New Meter Size/Type .'74 �' ',. /
E. Type of work performed or findings: Yti ,'%i P S %rid b 1114. /4 S 6 (-4'.
a. ' ,' /1,A) 1 te? - - 7/1.14 - i:1
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man -hours: , S Crew Members. (.r- P
11. List Materials Used:
6;7
12. If you had an iccidenciacident while performing this request. Did you report it? Yes or no
13. Water (. chides meta inspection: or fail
14. How many trips to do task?
Signature