2002_0423 •
WATER
Issued: y c'�IaZ Finished 4 Finishe Employee: Grid Map:
Name: 11 Address: +799 1 e Jf R t i i- P
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Leak 3. Maintenance 4. Qty
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 •
S. 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
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REQUEST FOR SERVICES: fJT
C �o.Aye Or , 7�
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 69160 69 7 Reading 0 9 Fr S
B. New Meter # (4)W cint Reading
C. Old Meter Size / Type ' fj (AGE- New Meter Size / Type ! ASV
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
14. How many trips to do task? , �d . . ' , �� ,-
Signature