2002_0830 WATER
Issued: 13-0 • 02 Finished: — Employee: Fr, Grid Map:
Name: Address' LO 7 - PAKR Y f `L '►9
Phone Number (HM): (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:
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 DOORICNOCKER
8. If Meter Change Out:
A. Old Meter # 11 13 (AA 3 Reading 1303 0 D
B. New Meter # 4 3 3 sty / Reading
C. Old Meter Size / Type 1 t) I'19 f 5 - WX New Meter Size / / Type t V i'Yl S-Zcit
E. Type of work performed or findings: Adz, • "f k a� !' ✓
-„ ,
c L w4-.
9. [f mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members: Frs01 . 41 etX -s'
11. List materials used:
l?. If you had an accident, incident while ing this reque�r ri;rt vnii "nor 1 !? YES nr NO
13. Water Utilities meter inspection: PASS or FAIL Post -it® Fax Note 7671 Date g13u Ipag s► 1
14. How many trips to do task? / To kAy toN jpN From ' ` —Ng1 1 J
1 y1
u A
Co. /Dept. , 1 K E! l i1 i LL-i r�l Co. Vl.T\ L1 - l l E,G+
Phone # Phone #
Fax # Fax #