2002_0513 WATER
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Issued: 5 Finished: 5/ 1 3\o Employee: Grid Map:
Name: Address: Cl O (n x-16- N OT
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. eR nca' 3. Maintenance 4. Qtd
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: ej N )1 1 Ole
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 it 9 t 2, 2 Reading C' O 1 O
B. New Meter # r4 -4 5fA Reading
C. Old Meter Size / Type J4- i3A6 New Meter Size / Type MAS1 - 62
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 accident ;incident while performing this request, did you report it? YES or NO
1 3. Water Utilities meter inspection: PASS or FAIL
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14. How many trips to do task? .1. . _ . . ..
Signature