2002_0521 WATER
Issued: S 1/1-1 10 L Finished 41111 i L Employee: Grid Map:
Name: Address: 5 IL La AU Ail f
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Enak 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 D. Lights E. Other •
REQUEST FOR SERVICES: A e.VL
7. If Meter / Service Leak, ClassifL: 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 R 4 11 1 241 7 / Reading 3 - 1 q i q
B. New Meter as 3 Reading 0
C. Old Meter Size / Type - .. New Meter Size / Type Ot i i6
E. Type of work performed or findings:
9. [f mainline or deep service repair, 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 wile 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' 1 &tier,• ' '''`-
Signature