2002_0422 WATER
Issued: _42402,___ Finished Employee: Grid Map:
Name: Address: (,,3 4 L All F PA-12Z
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Rank 3. Maintenance 4. Q
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: f Ili FTr2 c no - c - •
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 # 91t3 /904 - Reading 39°4g
B. New Meter i# 0fo / 4 0 F Reading . O
C. Old Meter Size / Type New Meter Size / Type • MA3 R.
E. Type of work performed or findings:
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
How many trips to do task? ("�' 14. EIo m y p Signature