2002_0916 WATER
Issued: q- 11o4ia. Finished: Employee: Tf O Grid Map:
Name: e p oh (A) �l 6 1 Address: P);'7 �I t�U
Phone Number (I (WK):
Check For: Accuracy Test Meter Leak i/ 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: Vole Eir Lfiji-
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
8. If Meter Change Out:
A. Old Meter -Z 3) ( 7' . 7 Reading /0 / lP 2 3
B. New Meter = 2 32 G I.57Z 33��jj Reading
C. Old Meter Size / Type fly ,rr / "x �" New Meter Size / Type J69—
E. Type of work performed or findings: (,vtk � w 6 acS 06‘ e- /1,eu/ 5 4 - otiv L �l
9 It mainline or deep service repa.r, describe type of pipe or service line and condition:
C4
[0. Man hours: Crew members: J
I 1. List materials used: 5
[2. It you had an accidentlincident .%hit e. .rming this request, did you repor it? YES or NO
13. Water Utilitie meter inspection: PAS or FAIL
•
14. How many trips to do task?
Signature