2002_0410 WATER
Issued: 4 . (0. 0 2 Finished: q 't O 2 Employee: Fri241.A Grid Map:
Name: Address: 4 0,5— 66
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $ems' 3. Maintenance 4. ghbd
Backflow Insp. k 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:
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 T a l 2 2 f? 6 Reading 170 8' &t a
B. New Meter 7 2(Q 414 -7 Reading
C. Old Meter Size / Type New Meter Size / Type
E. Type of work performed or findings: 1 of-e L der ( oar I
}I'S 4 e.„0,se 444 ito
9. [t mainline or deep service rera:. describe type of pipe or service line and condition:
10. Man hours: / 5 Crew members: F ,7 7
11. List materials used: We tJ el : �''
12. [t you had an accidenu'incident xhile performing this request, did you report it? YES or 0
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Signature