2002_0514 WATER
Issued: 1 141NZ, Finished: 5 l )4 1Employee: Grid Map:
Name: Address: y 1 L SL1 E✓
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
L Backflow Insp. 2. B ask 3. Maintenance 4. Qthe'
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: I P "IYelL
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 At q 12Z l 5 Reading
B. New Meter # D-G`{ I'-1 q3 Reading e
C. Old Meter Size / Type $ ' New Meter Size / Type ' MAST
E. Type of work performed or findings:
9. If 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. 1t you had an accident,incident chile performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL f
14. How many trips to do task?
,Signature