2002_0509 WATER
Issued: S Finished: S lq I bL Employee: Grid Map:
Name: Address: t 1 PCSDOtt)k) i✓
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. go& 3. Maintenance 4. Qt e"
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 r D. Lights E. Other
REQUEST FOR SERVICES: CL►,,1 p. Meri- _
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 # 1 Reading C) ci 5(
B. New Meter # 3,-)--SS 1 Reading Q5
C. Old Meter Size / Type Pik New Meter Size / Type s a g Ts
E. Type of work performed or findings:
9. [t mainline or deep service repa_, 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 •. hile 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? ,al p '- -i�-
Signature