2002_0513 WATER
Issued: s /3 Z- Finished: // 3/0 Z Employee: Grid Map:
Name: Address: 9h T f Ar7 Etu C
Phone Number (HM): (WK)
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. ea' 3. Maintenance 4. ghlid
Backflow Insp. A. Main Lame A. Purnp A. Line Locate
Blc low 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:
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 q I Z? ? . 1 I Reading ( vt14 1
B. New Meter Reading
C. Old Meter Size / Type t New Meter Size / Type 6jic i
E. Type of work performed or findings:
9. If mainline or deep service repa::, describe type of pipe or service line and condition: tLl
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10. Man hours: Crew members:
O 35
11. List materials used:
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12. If you had an accident; incident while performing this request, did you report it? YES or h
13. Water Utilities meter inspection: PASS or FAIL /
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14. How many trips to do task? . 1 � Z ,o g
Signature
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