2002_0513 WATER
Issued: S) )01. Finished 5113 J 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. Ronk Maintenance 4. Other
Backflow Insp. A Main Line A. Pump 'A. Line Locate
Bllow 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 ff D. Lights E. Other
REQUEST FOR SERVICES: (' VC.4c ttlefr4eQ
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 1 ? 2)00 A Reading /bO
B. New Meter i# t QA' Reading (X
C. Old Meter Size / Type BP,GEt. New Meter Size / Type 1A�
E. Type of work performed or Endings:
9. if mainline or deep service repay, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. if you had an accideno'incident while performing this request, did you repor•, it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL / /
14. How many trips to do task? ,
Signature