2002_0613 WATER
Issued: (('(2 - Finished: 66 )/3/OZ % n Employee: l 1^ 1(� Grid Map: (t't Name: r• b U 1 Address: ID e.0a±5
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. EtiMitr 3. Maintenance 4.
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dare 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
S. 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: INI '• S1it t t 2 1�,4� ,vim -4— - r K.
), t JLAAA)
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 41121tiEr ` J � { ? ?7 Reading , 07 /A-
B. New Meter # 6 ci Reading 4
C. Old Meter Size / Type %' ig New Meter Size / Type % ('AA
E. Type of work performed or findings: Oix.A- e. G 1A-�_ TAX" re- (' e1 ¥-
9. (t mainline or deep service re:a_. describe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date bifs_OZ I Pa°ges �
10. Man hours: Crew members: To SAY .1010■15014 From DE61 iNel
Co. /Dept. t� i g � ( 06 Co. WI L(fiLe.J
11. List materials used: W
Phone # Phone #
Fax # Fax #
12. (t you had art accidentiincideet htle performing this request, did you repot it? YES or NO
13. Water Utilities meter inspection: •' PASS or FAIL
14. How many trips to do task?
i 4
Signature