2002_0513 WATER
Issued: S f ) 3 )82 Finished .S 113 )I)7. Employee: Grid Map:
Name: Address:
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $m& 3. Maintenance 4. Qtbd
Bacicflow 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: elv)K Me
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 74 l , !') O Reading } 5' I (o
B. New Meter ;# ( 589 Reading 0
C. Old Meter Size / Type 1 €1L New Meter Size / Type TW ST12.
E. Type of work performed or findings:
9. [t mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
t?. If you had an accident, incident while performing this request, did you report it? YES or NO
l3. Water Utilities meter inspection: PASS or FAIL ate 14. How many trips to do task? �te ,
Signature