2002_0924 WATER
Issued: 9 o? 7 /Finished: Employee: Grid Map:
Name: A.,„__. - + Address: 7c/
i
Phone Number (HM): 393-0 373 (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. Co ess C T a , D. Lights E. Other
REQUEST FOR SERVICES:: C.•()C r.f (la-vr5r
7. If Meter / Service Leak, Classic;:: 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 deter = ) 43 4 5 4 Reading 7 V 9
B. New Meter = 612/ Reading /
C. Old Meter Size / Type A : New deter Size / Type / //M.
r ��
E. Type of work performed or `In dings: ,'' � � - � - �� � ` -
9 If main;:ne or deep ser.-ce repa::, describe type of pipe or service line and condition:
10. Man hours: Crew members:
1 1. List materials used:
12. [t you had an acc:den:.-c:dent performing this request, did you repor. it? YES or NO
13 Water Lnlities meter inspection: PASS or FAIL
14. How many taps to do task?
Signature