2002_0604 WATER
Issued: 41y /07. Finished Employee: Grid Map:
Name: Address: I S %oc i(kiAtrrJU
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &air 3. Maintenance 4. Other
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: (. CAA -Act P 4-
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 # ?0:4 1 ? Reading .;11 7c r
B. New Meter # DioctlGA9 Reading 16
C. Old Meter Size / Type 5 g New Meter Size / Type -
E. Type of work performed or findings:
9. It mainline or deep service rera, describe type of pipe or service line and condition: 1n n
om `r3 1
10. Man hours: Crew members:
1 l . List materials used:
E =
o x
u. o a u.
� Z
12. [t you had an accidenr; incident while performing this request, did you report it? YES or
13. Water Utilities meter inspection: PASS or FAIL 2 in
( .z's�
14. How many trips to do task? ri� Z
Signature 3
IS"
o 0 cts
0. 0 _a_