2002_0520 WATER
Issued: S 1 to DI- Finished: Si Z- 2 Employee: Grid Map:
Name: Address: 54 5 Le' A j A<<1 i.. `(
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Bask 3. Maintenance 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: Ai& . c R. 0 •
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 # 9 1 &LI ti 75 Reading 0 g
B. New Meter # ,yl (o 41 Reading 0
C. Old Meter Size / Type �g �AP�I New Meter Size / Type - lvt12
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. [t 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? " �f
Signature