2002_0412 WATER
Issued: Il /-- 'Finished: Employee: Grid Map:
` -.'16/. /a(
Name: A, J.0 _�_ � - - Address:
Phone Number (HM): ' 4 ..t g - (o 0 (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): /! 1
A. Barricades B. Cones C. Tap D. Li hts E. Oth – [ pN JA/ IAA e_
REQUEST FOR SERVICES: a 4 i' — I— e-0-4‹ n N
CC-V.` . icte.
7. If Meter / Service Leak, Classify: City t.. 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 # 9 (11 ° f t] ?s.1 Reading 0 q 579
B. New Meter T D.3 C '3 Reading (�
C. Old Meter Size / Type 5V ? (2e t s r A.) New Meter Size / Type -7 't MAS'Tr1L
E. Type of work performed or findings: 1713 / 1)(0 r- S - , Me
Vitt cit./0 &x._ 4 k e-)...) 5( S (c .
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members: Post -it® Fax Note 7671 Date 4125J02 (Pages■ 1
To 1 C A J From ( DEN i A
11. List materials used: Co./Dept. virtg. eum N4 Co_ UTl LIYI E3
Phone # Phone #
Fax # Fax #
12. If you had an accident/incident while performing this re■
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? ei,,,a,-Zoii.
Signature