2002_0514 WATER
Issued: Sli q'n L Finished 51! 416 Z Employee: Grid Map:
Name: Address: 51') I Legedg .
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp, 2. Kogii 3. Maintenance 4. Qt e
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: 6Avie. M �-
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 DOORKNi OCKER
8. If Meter Change Out:
A. Old Meter # q ti(5 Reading .a�35\
B. New Meter # -(04\ gS4 Reading
C. Old Meter Size / Type $AC,Ee New Meter Size / Type SA MASTER
E. Type of work performed or findings:
9. If mainline or deep service repa.r, describe type of pipe or service line and condition:
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10. Man hours: Crew members: SA \
l 1. List materials used: 4t
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12. If you had an accideno'incideni while performing this request, did you report it? YES or N. J
(3. Water Utilities meter inspection: PASS or FALL
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14. How many trips to do task? _ z
Signature
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