2002_0411 WATER
Issued: Finished _ 4 f 1 II p 7 Employee: Grid Map:
Name: Address:
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re - Read
1. Backflow Insp. 2. &PAL 3. Maintenance 4. Qt e
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: "O/ EQ e Ct Awr C) cJT
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 # elq I o C' 553 Reading 1 1 1
B. New Meter aIo I ( a 1 g Reading
C. Old Meter Size / Type d-f'12 New Meter Size / Type MA4`TE
E. Type of work performed or findings:
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9. If mainline or deep service repair, describe type of pipe or service line and condition:
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10. Man hours: Crew members: o ° d • LL
11. List materials used:
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12. If you had an accident;'incident while performing this request, did you report it? YES or o
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13. Water Utilities meter inspection: PASS or FAIL Zil x -7 3 �� f�J/ 14. How many trips to do task. ��� oo 1 �) 4 t cu
Signature
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