2002_0410 WATER
Issued: 4 41 IC le is Finished: 4 / 1 /0 Z, Employee: Grid map:
Name: Address: I((o AO/
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Phone Number (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Rook 3. Maintenance 4 .4SkQ
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: METEIe C hie O J'f"
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 -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # Reading /43Gn
B. New Meter # 3 Reading moo
C. Old Meter Size/Type: _ D New Meter Size/Type y S4 k._.
E. Type of work performed or findings:
N
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9. If mainline or deep service repair, describe type of pipe or service line and condition: s
a
0 . _ - _
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10. Man - hours: Crew Members. "
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11. List Materials Used:
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12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
4) i 126
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13. Water Utilities meter inspection: pass or fail � i 1
14. How many trips to do task? = "
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S ignature C` ... , -4 v/3 0 0 . .. a,