2002_0514 WATER
Issued: s Finished: / 1 - 1 (oL Employee Grid Map:
Name: Address: CS) 2 ) Les I,i,r
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Boak 3. Maintenance 4. Oth
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: ME #EL CN ARIG
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 4 91 7 71881 Reading e68
B. New Meter # Reading 0
C. Old Meter Size / Type � P(- New Meter Size / Type t 5 .
E. Type of work performed or findings:
9. If mainline or deep service reran, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. [t you had an accidenu incident while performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL (1/0,1
14. How many trips to do task?
Signature