2002_0604 WATER
Issued: Finished Employee: Crud Map:
Name: Address: 3(X1 / nM6(
Phone Number (HM): (WK)
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $O& 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: C.MA-n,i P. (901'
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 # q O / 7S cj Reading / C' '(,S_3
B. New Meter # / O895' Reading 0
C. Old Meter Size / Type ' Okpc- csieA) New Meter Size / Type g MfN 2 —
E. Type of work performed or findings:
9. It mainline or deep service reps:: describe type of pipe or service line and condition:
10. Mart hours: Crew members:
11. List materials used:
12. [t you had an accident;incident xhile performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? _____4444_,L
/' ir►��
Signature