2000_1114 1 e-
WATER
Issued: 1 114100 F'misbed: Employee: 1. AL.—, Grid map: �--
LOP) Name A ddress: I • . I _ I I
Phone Number: (FILM) (WK):
Check for Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
E. Backflow Insp, 2. Remit 3. Maintenance 4. Qtst
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
3. Reason for failure: A. Electrolysis B. Nees 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 f. Services: , / _� J I �` I ' •
AI .pia
7. If Meter/Service Leah Classify: - City: Customer
A. water Lou (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 Units Miles Hrs Equipment
A. Old Meter Z i J& /3 Reading 6 `/3'
B. New Meter # Z b c/1,5'4 '2 Reading -
C. Old Meter SizeType: D New Meter Sizellype 7e' X y4, r17.,9 E. Type of work performed or findings: f 1 a 6G7 , - /� , v e - s --CAA - t/ LS
1 4,.1
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man -hours: 1 S Crew Members. ‘A',
11. List Materials Used:
12. If you had az accident Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task?