2002_0514 WATER
Issued: 411 4 ( 2... Finished S 1<d l 0 L Employee: Grid Map:
Name: Address: g 1] LE:S L.I�
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $e,' 3. Maintenance 4. Qthd
Backflow Insp. A.. Main Line A. Ptanp A. Line Locate
Blflow Celt. Date B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D. Excavation
E. Safety •
5. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation D. Other
6, List of Safety Equipment at Site (if applicable):
A. Barricades B. Cones C. Tape D. CAA E. Other
REQUEST FOR SERVICES: t 4 V CA- MO crr
7. If Meter / Service Leak, Classify: City Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # C1 2:2.-1 Reading 1 3'7$
B. New Meter T X4 152 Reading Q
C. Old Meter Size / Type -4"if New Meter Size / Type Man-
E. Type of work performed or findings:
9. If mainline or deep service rera::. describe type of pipe or service line and condition:
10. Man hours: Crew members:
I 1. List materials used:
l?. If you had an accident;incidert x tle performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL n
b,10-
14. How many trips to do task? /��/,�,�'
Signature