2002_0514 WATER
Issued: 4111_02,-__ Finished: 51/ Employee: Grid Map:
Name: Address: 'K-it L , es J.,4
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $• 3. Maintenance 4. gg1L4
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: MOM IIRh
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 7 (I ? ? l' L, Reading j P-551
B. New Meter # a44 'Mg Reading (7
C. Old Meter Size / Type k PPWit New Meter Size / Type h TM-
E. Type of work performed or findings:
9. It 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 accidentiincident Haile 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