2000_0627 . N (.?ui ill .ey
. .
WATER
Issued:/( Finished: - 7 /66 Employee: Grid map:
Name: wat J L Pja 0I Address: 6. &Lfl -
Lttk
Phone Number: (HM) (WK): ✓
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. ile/
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
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: rn ✓ in r- -_S
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 # Miles Hrs Equipment
A. Old Meter T y 0S % el 0 Reading 2 - 6 9g
B. New Meter # 1 4 Reading -&—
_
C. Old Meter SizeiType: t X 1347o D New Meter SizeiType - �7Y Mat 1 '7
E. Type of work performe. or findings: 0 L a 1 L e' i/5,,`7I
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: ? 5 Crew Members.
(r , O- c,) c,
11. List Materials Used:
12. If you had an accidentIncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: . fail
14. How many trips to do task?
Signature