2002_0520 •
WATER
Issued: ZD Finished ___5_1212,4"/„Employee: Grid Map:
Name: Address: S 17 t ...€7A A l i
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $,t 3. Maintenance 4.
Backflow Insp. A. Main Line A. Pump • A Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D. Excavation
E. Safety •
5. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation D. Other
6, List of Safety Equipment at Site (if applicable):
A. Barricades B. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: 14x c' C. a,.1 X4 8 c
7. If Meter / Service Leak, Classify: City Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # 8 en VC(o )$ Reading 1 i t 1S
B. New Meter # a10 4 1 -th, Reading
C. Old Meter Size / Type New Meter Size / Type ' l"tZ--
E. Type of work performed or findings:
9. [t 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 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? - ,
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