2002_0513 WATER
Issued: 5115 \et Finished: 5 )13 102 Employee: , Grid Map:
Name: Address: q 0 1.--E f ,1
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Reoair 3. Maintenance 4. Othee•
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: CAANIV , 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# q05 %60(k Reading 13 (0Sq
B. New Meter # Reading d
C. Old Meter Size / Type 54 FAA New Meter Size / Type 5 1 4 1
E. Type of work performed or findings:
9. If mainline or deep service repa: , describe type of pipe or service line and condition:
10. Man hours: Crew members:
H. List materials used:
2. If 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?
Signature