2002_0509 WATER
Issued: S` t t (d ?, Finished S l 6 ( , 0 Z , Employee: Grid Map:
Name: Address: I
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $eta' 3. Maintenance 4. old
Bacldlow 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: CliwJcie
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 # e1 I D-2.1 q l f' Reading /0 L 94
B. New Meter 2-a(e3 l Reading 03
C. Old Meter Size / Type f K �L New Meter Size / Type 57 8" MASTER-
E. Type of work performed or findings:
9. Ef mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
l 2. It' you had an accidenu"incident while performing this request, did you report it? S or NO
t 3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? _ iI - l ' A /14,-
Signakure