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2002_0521 WATER Issued: Si 2 i )(1 . Finished: 5121/a- Employee: Grid Map: Name: Address: '(` r Li: A v A il y' Phone Number (HM): (WK): Check For. Accuracy Test Meter Leak Check Water Pressure Initial Meter Relocation Inspections Re -Read 1. Backflow Insp. 2. ems' 3. Maintenance 4. Qtly 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: /i : - 7i ' r;• a4. , c) 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 DOORXNOCKER 8. If Meter Change Out: A. Old Meter 4 1C c - 4C - 1 Reading S 1 X1.7 7 B. New Meter 4 34fiy ¢ 643 Reading 0 i C. Old Meter Size / Type �' Pp. e e - 11 0 9,) New Meter Size / Type - N64% — r E. Type of work performed or findings: 9. It mainline or deep service rera.:, describe type of pipe or service line and condition: 1 10. Man hours: Crew members: ©;'� 11. List materials used: o a n CO 12. It you had an accident incident wile performing this request, did you report it? YES or r 13. Water Utilities meter inspection: PASS or FALL > / / 14. How many trips to do task? _ dli / 11 ' Z X Signature LL 7. I N 0 0.