2001_0920 d ✓r
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lid)dejfil �J / WATER tr _
Issued: (( / iv• O ` Fietisbe� Employee: Grid asap: —_
Name: L.�iALL, ■c .Td/L _ Address: 1 �'j L J 0 c4
Phone Number (.1) (WK): - - k
Check for. Accuracy test: . Leak: Check water pressure:
Initial meter relocation insx Re -read
1. Backflow Insp. 2. $goak 3. Maintenance 4. Qt
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
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. Li is E. Oth
A. er
Request for Services: 1 / ` --t
7. If Mete:'Se :ice Leak: Classify: City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Wu Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
S. If Meter C;.a: ge Out: Unit 4 Miles Hrs Equipment
A. Oid Meter ; •, Q bs3 b Reading 15 6- r 4
B. New Meter 4 - • l e Reading
C. Old Meer SizerType: Arlo • a , D New Meter Sizefrype 5 4 MA S1 ..
E. Type of woric perforrned or f ndin :: Mt fk.e.. sf*. E ,11-
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: 1 Crew Members. 1
1 1. List Materials Used:
12. If you had a- ac ::dean?- c.drzt while performing this reques :. Did you repor::t7 Yes or no
13. Water LoImes meter iespe^- :en: pus or fail
14. How mut7 trips to do task?
Signature 6tS1-r C