2002_0514 WATER
Issued: 4 14Int. Finished: S' In t Employee: Grid Map:
Name: Address: :a[.3 Lex t-}- LA
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. gepa 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:
Me4 C.
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 Y q n 5 g'S ( Reading f?
B. New Meter # .(o ` u I Reading 0
C. Old Meter Size / Type S/ { New Meter Size / Type �f� MPS VL,
E. Type of work performed or findings:
9. [f mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
l 2. If you had an accident incident chile 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