2002_0520 WATER
Issued: 0 Finished: l 20 101, Employee: Grid Map:
Name: Address: 54 1 (c : A-V 41 l
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $Ca" 3. Maintenance 4. Qthgt
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: M aPAAAJ g ,p F) UT
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 # C 22 .7-6 0 `j Reading 31 kR 7
B. New Meter ;# -V-(oLt 1 ( c(q Reading le
C. Old Meter Size / Type 5 /� RR A CrArtz New Meter Size / Type 1VAR-r
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. If you had an accidentiincident ..•bile 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? / ' if /4/
Y P
Signature