2002_0410 WATER
Issued: 1 1/10 / 0 Z Finished: 1 1/10/07.- Employee: Grid map
Name: Address: roaci 14i (1
Phone Number. (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. flackflow Insp. 2. Repair 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: )42CTEL C, 40-4.1e 0
7. If Meter /Service Leak: Classify: - City: Customer
A. Water Lou (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 # qI e_7117S Reading ,a3e/a.5
B. New Meter # S �. Readingmo
C. Old Meter Size/Type: Of D New Meter Size/ Type MA>TC2
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man - hours: Crew Members.
11. List Materials Used:
12. If you had an accident'Incident while 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 (4L1I 2- .r Cif