2002_0410 / WATER
Issued: `Ile ° OZ Finished: 444. 0 z- Employee: Fr Grid Map:
Name: Address: 313 14-
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. goat 3. Maintenance 4. Qthd
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 # ( 22 - 00 42 Reading K(j 573°
B. New Meter n 242 1 4 /qZ Reading 0'
C. Old Meter Size / Type 4" Q B4 r New Meter Size / Type 7;X A3hr Aided--
E. Type of work performed or findings:
9. [t mainline or deep service reps:, describe type of pipe or service line and condition:
10. Man hours: S Crew members: F 7
11. List materials used: kJ
12. [t you had an accidentiincident wile performing this request, did you report it? YES or C)
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? �
Signature