2002_0410 WATER
Issued: [f,/a- 0 Finished: 1 1- /e` e2 Employee: FiX Grid Map:
Name: Address: 3f le
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Rep i 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:
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 # q, Z zLOl9 Reading 'f0 % /6
B. New Meter n Z 4/14123 Reading $'
C. Old Meter Size / Type % bC 7 4 8+ New Meter Size / Type /x 4 "-O' 4-7
E. Type of work performed or findings:
9. If mainline or deep service repa::, describe type of pipe or service line and condition:
10. Man hours: / S Crew members: r 1
11. List materials used: /1/,., +A✓ //Yi - -7f✓t
12. If you had an accideno'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? 1
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