2002_0327 I o
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b rt WATER
X Issued: ] Z )- Finished: ✓ Employee: Al C/06 c3 Grid map:
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N ame: Address: j 4 /0 S - lia l /I
A Phone N (HM (WK): /
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- 01 Check for: Accuracy test: Meter Leak: Check water pressure:
1 Initial meter relocation inspections Re -read
° 1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp A. Main Line A. Pump A. Line Locate
I:4 q?S Bow Cert. Date B. Valves B. Water Tower B. Line Locate
IT
tQj Re - Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equpment
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:
// 'f' .11 ■• 0
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 # 'l22) 7 7 Y Reading ,.O/ 33 , 6/6 3 Jd
B. New Meter # 9 9 VP/ ( Reading 0
C. Old Meter Size/Type: 5/A /3 R4 P r D New Meter Size/Type r/' Al A - rZ
E. Type of work performed or findings
9. If mainline or deep service repair, describe type of pipe or service line and condition:
5 a- //
10. Man - hours: H� Crew Members.
11. List Materials Used:
/MORE% 1 '- c likel
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: 67 or fail
14. How many trips to do task?
Signature g. i /'/ y� 1 -6`,