2002_0618 WATER
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Issued: / 0 -Finished: 67 'f l Employee: Grid Map:
Name: rn -: _ Address: / _ �/ _
Phone Number (HM): (WK): 09' Sse9 - /1
Check For: Accuracy Test Meter Leak Check Water Pressure .
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
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 /
REQ ST FOR SERVICES: L,.' 4 _ . /'GO �g - G(J
•
7. If Meter / Service Leak, Classify: City Customer
1
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORICNOCKER
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8. If Meter Change Out: J �j �j
A. Old Meter - . 7 Reading 7 - � ,
B. New Meter * C7 ) s Reading '�-
C. Old Meter Size / Type /1- S er } New Meter Size / T e (' _ , C
E. Type of work performed or findings: ( Gi°- Ge) 7")-Z., -I o A r
9. If mainline or deep service repair, describe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date 6 OZ Ipa 2
10. Man hours: Crew members: L, To KAY J0f05ots From DEE31 1 , m o t
11. List materials used: co.IDept. wit. B1 LLl1J4 co. uT! L1 Ti E5
Phone # Phone #
Fax # Fax #
12. If you had an accident/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? --f/j Signature