2002_0520 r i WATER
Issued: 5 I O U L Finished: S Zo I 02 Employee: Grid Map:
Name: 11 Address: __VIZ_ AV
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Back low Iuso. 2. Leta' 3. Maintenance 4. glthd
Back low 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 •• •
S. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation D. Ether
6, List of Safety Equipment at Site (if applicable):
A. Barricades B. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: C.0 NVL h••($4 t•-•Li
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 DOORKVi OCKER
8. If Meter Change Out:
A. Old Meter : 1 22- ' 7 Reading 1 73 fl
B. New Meter # a (O 414 R`7 Reading /
C. Old Meter Size / Type New Meter Size / Type ..
E. Type of work performed or findings:
9. [f mainline or deep service repel, 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 repor. it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL /
14. How many trips to do task? .411/ �� / ��