2002_0521 WATER
Issued: Z L Finished: S 2 1 (t) L Employee: Grid Map:
Name: Address: 5 .i) I /. P ,.{ 1 Cy
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. kg& 3. M_ 4. Qhq
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: )UI LiC1L C ,i'1
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 6, 5-)..6 Reading S
B. New Meter ;# ,*j 3 5 Li I Reading 0
C. Old Meter Size / Type i I/ 3 il( -'n- New Meter Size / Type 1 ' 1 'lc - it iZ.
E. Type of work performed or findings:
9. It mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. It you had an accident, incident •A performing this request, did you repots it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL p
14. How many trips to do task? Pat/fi tat -.-
Signature