2001_0920 ki k " ) (rA o i vi•11 6.1161)::
WATER � pc ?' X0 - Oiiaisbed: Employee: !/:1- 3■ . Grid
1
Name: 1.10.4 VLc!4..4g, Address: 35 :.•..a10
Phone ?cumber. cle-f) (WK): -24
Check for A :cw1cy test: Meter Leak: Check water pressure:
Initial meter relocation iaspe :rioas Re -read
1. Hacktlow Insp. 2. jtepair 3. Maintenance 4. QteL
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert Dace 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
S. 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: r 1-19-14■6121)------ _
7. If Meer: Se :lice Leak: Classify: City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Wu Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Me:e: C:a: g: Out: Unit # Miles Hrs Equipment
A. Old Mater * y f L
{? V 3 a 96b Reading I/ 3 7 Lbfej
B. New Meter 1 2 '/ ,3.5 Reading 0
C. Old Meter Sizerr pe: D New Met Sizefrype .-- /'1
E. Type of work performed or findings: 1r j/4..5 ,y24
<-'h •Iiv)4 -iFi-rz o
9. If mainline or deep service repair, describe type of pipe or service line and condition
10. Man- hours: I Crew Members.
11. List Materials Used:
12. If you haci i . ac :identr ?-c:de :c while performing this request. Did you repor. it' Yes or no
13. Water (,'alines :peter irspe:tort: pass or fail
14. How many trips to do task?
Signature i10..9.,_, t 2 ,