0000_0820 WATER
Issued: I lD 0 Finished: Employee: d tX e) r Zu. Grid Map:
Name: lyc `7 i i n Address: 11(3C C et
Phone Number (ICI): t-ra— 4(c)3— () l7 (WK)
Check For: .accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Repair 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. 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: "Mir udal.ty o{-4 — v ( 05t2di lira ex ht7;d
7. If Meter / Service Leak, Classify: City Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
Of B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out:
A. Old Meter ;# Reading
B. New Meter # Reading
C. Old Meter Size / Type New Meter Size / Type
E. Type of work performed or findings: ((A so S 4-0,0 b,z 6 )f p AU / 6 o
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9. [f mainline or deep service repair. describe type of pipe or service line and condition:
10. elan hours: 2' / Crew members: /
11. List materials used: COrh r • ' r'' , Lei • a,54 L 1: 11 O'a,01, 1 - trt',i - ; 11 .4/-1 c lemt.eze Si ! e o 4 (v.. t. j v .
12. [f you had an accident/incident while .rming this request, did you report it? YES or NO
13. Water Utilities meter inspection: PAS or FAIL ,,
14. How many trips to do task? '2 >
Sure