2002_0612 WATER
Issued: (r 1- aZ Finished: ' / ..ployee: 01W - tie, Grid Map:
Name: Address: 2.55 Delta
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Ikpgji 3. Maintenance 4. Qtd
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: PC Vii _ rn� w*r. ( * B45 n-71 53)
C,isi - Drrt ' Yeci,t"ect IYUA big 4r fj I1n0n+fis
Please (ems door ) J V
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 T x/ 5777 S Reading C 4 , '74 V
B. New Meter 76 4 // 4 5 Reading O
C. Old Meter Size / Type 5 ,-- ; (r New Meter Size / Type MTV
E. Type of work performed or findings:
9. (t mainline or deep service re.a. describe type of pipe or service line and condition:
10. Man hours: Crew members: Post - it® Fax Note 7671 Date b..12_02.lPag s►
it. List materials used: TO Kqy J01.04Sot From rfg (►SRAM
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Co. /Dept. `� 1 LL1 P46 co. DEN
LIT(
Phone # W `� �J Phone #
Fax # Fax #
12. 1t you had an acctdenoincideet atle performing this reque
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? 1
Signature