2002_0422 /
102_
WATER
Issued: 4/1 4e2 Finished: ql 71 Employee: Grid map:
Name: 6161 {!{ Address: 64./Z__ LJ kF R4
Phone Number: (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re - read
1. Backflow Insp, 2. &pair 3. Maintenance 4. Qtha
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: tt CIAAIL.tt P n Tr:
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 -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # q l f 9 d y6, Reading 2
B. New Meter # .2 .26 `I 'i-9(? Reading
C. Old Meter Size/rype: D New Meter Size/Type AS ilk
E. Type of work performed or findings:
r
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials Used:
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? ,
Signature eJ it.