2002_0409 WATER
Issued: q_1 I0 ? Finished: (4 I 0Z, Employee: Grid map:
Name: Address: ! 0 9 S, 1 ell 1 y
Phone Number. (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair k 3. & - 4 . Q
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: E; F( C_AAA Ne e 0 c TT
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 /6 75'7
B. New Meter # J al, El Reading 000
C. Old Meter SizerType: FS Ar r' t2 D New Meter Size/ Type $>g rot &FI2-
E. Type of work performed or findings:
, d
9. If mainline or deep service repair, describe type of pipe or service line and condition: A g
o@
.
o A ,.
Crew Members.
10. Man-hours: d
au E it
o x
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11. List Materials Used: D
CD
C
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 X "7
14. How many trips to do task? a is
�,f O c
Signature * UJ- ti - a x