2002_0509 WATER
Issued: 5 I b Z. Finished S 1.1 0 Z Employee: Grid Map:
Name: Address: I OF i—f!/V1:S ct 1111
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Ezzak 3. Maintenance 4. Lad
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 kAM1 e.
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 q 1 72 l et 27 . Reading l O 14
B. New Meter Reading cZ
C. Old Meter Size / Type New Eat. New Meter Size / Type S*
E. Type of work performed or findings:
9. [t mainline or deep service repair, describe type of pipe or service line and condition:
10. Mart hours: Crew members:
11. List materials used:
12. If you had an accidenc'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