2002_0509 WATER
Issued: 5 \ ct I bZ- Finished_ 5 `4 l r)2 Employee: Grid Map:
Name: Address: / D 9 L-Ak.) S 4)5
Phone Number (I IM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. eR pa 3. Maintenance 4. ghlid
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
S. 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: e AW[e Mt4e
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 # 9 z-Z1 qal Reading al 3&3
B. New Meter # aL 3 Z) Reading Q5
C. Old Meter Size / Type -5 4 New Meter Size / Type f ✓1_
E. Type of work performed or findings:
9. If mainline or deep service re✓a.r, 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 FAIL / ^
14. How many trips to do task? ( l Aif t i
Signature