2002_0410 WATER
Issued: 7 ` t ®• p2 Finished: `J • /0 - &Z Employee: cc-AA-4 Grid Map:
Name: Address: '/00 g e-
Phone Number (I f): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow sp. 2. Bzair 3. Maintenance 4. Old
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:
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 4' ° ?s 31 t / Reading $r2 2 g 2 0
B. New Meter T Z C 1 y Z r Reading
C. Old Meter Size / Type
fie e;€4 s �8 New Meter Size / Type 4 ifttsk
E. Type of work performed or Endings:
9. [t mainline or deep service repa::, describe type of pipe or service line and condition:
10. Man hours: / S Crew members: r /
11. List materials used: A/ [i to‘ /7 a- �G i?,
12. [t you had an accident/incident H aile 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? t
Signature