2002_0520 WATER
Issued: 517.0 16 Finished 5 (24 I f i?, Employee: Grid Map:
Name: Address: 5°Z y
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
L Backflow Insp. 2. Bait 3. Maintenance 4. Otbei
Backflow Insp. A. Main Line A. Puznp 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: M .- f'-1 w I OCR
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 R q OS R 904 Reading -
B. New Meter # .2-(,,y! c(.5 Reading
C. Old Meter Size / Type ? i s r io New Meter Size / Type ; 1 iv\SI R
E. Type of work performed or findings:
9. If mainline or deep service repa.r, 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':? YES or NO
13. Water Utilities meter inspection: PASS or FAIL �G
14. How many trips to do task?
Sianahirr