2002_0514 WATER
Issued: Finished: 51 44 /b?_ Employee: .. Grid Map: _4.4
Name:. Address: .- k e iY l 1 _ w7
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Mak 3. Maintenance 4. Qth
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:
CIAAxtif
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 X 7C -58 ") Reading /3 ii
B. New Meter (ol 1 1 441 Reading
C. Old Meter Size / Type % 13AF., - e2 • New Meter Size / Type ' 1'1
E. Type of work performed or findings:
9. [t mainline or deep service re e:, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. If you had an accidenoincident while performing this request, did you report it? YES or NO
l 3. Water Utilities meter inspection: PASS or FAIL 47
14. How many trips to do task? eArm
i gnature