2002_0509 WATER
Issued: 614 it, 2_ Finished: 5 /0 Employee: Grid Map:
Name: Address: , I DLI LfigIZONE
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Back low Insp. 2. eR pasr' 3. Maintenance 4. Q111 e'
B ackflow 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: M644 14016
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 # / a.aao /.5 Reading / Cd.O
B. New Meter # a_C 3 an.. Reading S
C. Old Meter Size / Type 5'8 BPS New Meter Size / Type
E. Type of work performed or findings:
9. If mainline or deep service repa;r, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. [t 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? ,te
Signature