2002_0509 WATER
Issued: , Sig /b? Finished: �l 6/ l 6 Z Employee: Grid Map:
Name: Address: I 1 i LARSI OWL
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Re,' 3. Maintenance 4. Qtbd
Backflow Insp. A Main Line A. Pwnp 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: MEAV2 CAA A/0c
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 T Cl i(,aS(o g o Reading / 313(o
B. New Meter # 1 Reading
C. Old Meter Size / Type s i 13P t�, New Meter Size / Type *
E. Type of work performed or Endings:
9. [t mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
l 1. List materials used:
12. If you had an accident; incident while performing this request, did you report it? YES or NO
l 3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? di/4 4.4.
Signature