2002_0520 WATER
•
Issued: _5424 Z— Finished: 20 mp loyee• , Grid Map:
Name: Address: S T
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Inso. 2 - Ronk 3. Maintenance 4. gbd
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: t/tAT4n -n
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 DOOR MOCKER
8. If Meter Change Out:
A. Old Meter T 91 ?2J 72 Reading 1 2.4'4
B. New Meter # �!� <I- /c/R—'1 Reading
C. Old Meter Size / Type � RA(3-572— New Meter Size / Type
E. Type of work performed or findings:
9. [t mainline or deep service re•a=, describe type of pipe or service line and condition:
10. Man hours: Crew members:
1 1. List materials used:
12. [t you had an accidenu"incider t 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? / `.