2002_0627 WATER
Issued: (Q -moo 02 Finished: 14P (72-/ Employee: Char 116 Grid Map:
Name: V*. 1714610i v C Y2Ute t Address: 201 Cho e ry t .tk-
Phone Nurnber (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Matt 3. Maintenance 4. Qt ti
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. nn Other �
REQUEST FOR SERVICES: . oil � Che.CL 4h( at,C(.urdt'.t� 1 . _., r" lls was
f�.st Gate_ tin, Pee. 2.t» pee Ohts + mover. �I
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 # ,..51,;.7 7/ 4 Reading ei 1.34 0
B. New Meter = a.e 9/ V 3e Reading 0
C. Old Meter Size / Type New New Meter Size / Type
E. Type of work performed or Endings: Manz_ (11. e, OJn
9. [t mainline or deep service re_a_ :::.-.scribe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date t I # of ∎ 2
� C pages 4
10. Man hours: Crew members: To a j01-04504 4 From MBA (f r' AM
Co. /Dept. JA111 Co lJl'( - ( �..� t ( GS
1 1. List materials used:
'""em (e11. l rr 8 1 L . L s C Phone #
Fax # V�� �� V t� 11111 Fax #
1 [t you had an acc :dent :incidert Z_ : :e performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL
Z,
l4. How many trips to do task? 6,(4..ft, .d,...._,/,w_._
Signature