2002_0411 WATER
Issued: 4111 J n z Finished: 9// 1)o Z Employee: Grid Map:
Name: Address: 5 c LIKE f �`21L
Phone Number (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Bo& 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
REQUEST FOR SERVICES: Mere-re- e-G c,e ou
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 # q ( ) q / 2 Reading J04
B. New Meter # . A4 1 v+4 Reading C lO
C. Old Meter Size / Type New Meter Size / Type t` Vt5 -- 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 42,(-1
14. How many trips to do task?
Signature