2002_0520 WATER
Issued: S' ( ?2) I fli . Finished: Employee: Grid Map:
Name: Address: 501 LE.A VAL Lr 9
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $at 3 . M— 4. Old
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: Q' -0- 60-
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 q ( ( e -SS3t-1 Reading ay 03
B. New Meter # X10 q i LI Reading c2`5
C. Old Meter Size / Type ' 846-61 New Meter Size / Type 5 ;4 - ts".6--reR --
E. Type of work performed or findings:
9. If mainline or deep service repay, describe type of pipe or service line and condition: Vi j
8 Q S
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10. Man hours: Crew members: °' o ° "
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11. List materials used:
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12. if you had an accidents incident •x•hile performing this request, did you report it? YES or o =
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13. Water Utilities meter inspection: PASS or FAIL _ " cts
14. How many trips to do task? 1 ' • • • = Cr. a 4,
Y0 N
Signature o 0 0 L co
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