2002_0509 WATER
Issued: 51q/ 0 Z Finished Sig /62... Employee: , Grid Map:
Name: Address: /aR LANSDn GjNe
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. e$, wag' 3. Maintenance 4. Qt .d
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: N Tt. (L P P.
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 # Oct f 00 5 l 0 Reading / /'F'Z.
B. New Meter # 41 S 85 Reading 95
C. Old Meter Size / Type $ o New Meter Size / Type 1YL-t R.
E. Type of work performed or findings:
9. If mainline or deep service rep,air, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. It you had an accident, incident while 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?
Signature