2002_0509 WATER
Issued: 5 IG / 0 7 — Finished: Sig/02- Employee: Grid Map:
Name: Address: (o 1- PWSDOtWe
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. Q tic
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: M & 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 qi [o:0 S<( Reading iiiiigigtat 1 a O
B. New Meter 2 (v Z1 f .S ((o Reading Ci
C. Old Meter Size / Type 1 GETL New Meter Size / Type 5* R ANSTE�
E. Type of work performed or findings:
9. (t mainline or deep service re;;,a.rr, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. If you had an accident incident while performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FALL
14. How many trips to do task?
Signature