2002_0830 WATER
Issued: 13D11 Finished: Employee: I Jlkl2 Grid Map:
Name: tArr ft Address: ) 2 A l i .(hl eArc'S{
Phone Number (ILNI): (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 nn C. Tape D. Lights E. Other
REQUEST FOR SERVICES: PC55i ble
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 I, DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # 9 1 n 3C) Reading .9 ,
B. New Meter # 9-5;95'9 s - Reading
C. Old Meter Size / Type / ), ;5 New Meter Size / Type r/ f^1as j��2
E. Type of work performed or,ltndings: � �i` ri r. �?� J %/�.�lL�+ 6 /gif Sri ��vz
SA/ /, >/ � -y L" J,; ;a e - /ire /c Pg. zit o %c6
f 4 .d /2/k7z-4_ (9 J/ St= 342,0 'D /r i 44-4. ]p /;� 4 -s;`
9. It mainline or deep ser repair, describe type of pipe or service line and conditio .
[0. Man hours: Crew members:
11. List materials used:
12. If you had an accident:incident .chile 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?
Signature