2002_0514 WATER
Issued: Finished 5 107 , Employee: Grid Map:
Name: Address: s Les Li e,
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. e$oazr' 3. Maintenance 4. Oth
Backflow Insp. A. Main Line A. Punip • - A. Line Locate
Bk±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: eL
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 C I ZZX clC S Reading 2( (,41
B. New Meter # 2 ( 4I 6 1 O Reading T
C. Old Meter Size / Type New Meter Size / Type '- U.L
E. Type of work performed or Endings: _
9. [f mainline or deep service repa.r, 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
13. Water Utilities meter inspection: PASS or FAIL 14. How many trips to do task? 46AL I MSS'
Signature