2002_0509 WATER
Issued: 4� f y / o Z— Finished: S /t /rt.. Employee: Grid Map:
Name: Address: S7 LEE D R
Phone Number (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &Elk 3. Maintenance 4. Ot e
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: (ewe 1
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 # 4 M C) Reading CXp6
B. New Meter # 2iC, 1.5 Reading
C. Old Meter Size / Type .6R New Meter Size / Type 5 f MA_
E. Type of work performed or findings:
9. It mainline or deep service repel, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. [(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? CA-lif
Signature