2002_0809 �� // WATER
Issued: n oo Finished: Employee: Frra11ki Pi Grid Map:
Name: wk. 1° I,th n Q� � Da f(� 1l 1 Address: 032 (�°'1 ie3t '
Phone Number (ITM): (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: 1 t'tr• U
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 # 2 3 let 1 Reading Z5
B. New Meter # ZI a " ?'I 5S Reading
C. Old Meter Size / Type MJIFS7i jt 5 /gx 3/? New Meter Size / Type ism sr-Ex /max 3/�/
E. Type of work performed or findings: T
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: r Crew members:
11. List materials used:
12. If you had an accident/incident while •- orming this request, did you report it? YES or NO
13. Water Utilities meter inspection: PAS or FAIL
14. How many trips to do task?
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