0000_1024 ld (,w t'le
WATER -
Issued: _ `. Finished: Employee: Grid map:
Name: . Address.. t i
Phone Number: (KM) (WK):
Check for Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re - read
1. Backflow Insp. 2. Reoair 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. Neste 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 Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out Unit R Miles Hrs Equipment
A. Old Meter 4 s 6 06 ie Reading 6 eo
B. New Meter 4 _ -'_ -.3 Reading �e9""
C. Old Meter SizeType: a / a a'4G = D New Meter Size/Type Ve 7y "l/"/
E. Type of work performed or findings:
9. If mainline r deep service repair, describe type of pipe or service line and condition:
REP SE4w+1 ( �� OH : C , t • -41d
PiPfil -0,E r9,t1 C SAz Hr SySTia.- D. K .
10. Man -hours: Crew Members. G ,
11. List Materials Used:
RePi4cL G L"41tt -!Icy ' -" /`Ic
1?. If you had an accident Incident while perfo • g this request. Did you report it? Yes or no
13. Water Ltilicies meter inspection: p or fail
l4. How many trips to do task? i
Signature