2002_0423 •
WATER
Issued: q11.3 0 Z Finished 4 23 0 Z Employee: Grid Map:
Name: Address: K.SN )J KE Ul •.w OR_
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Inv, 2- Email 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: NIE C11, to Oo
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 # 09 a N 7 t- Reading ago? 3
B. New Meter # g,'S aO a'4 S Reading 0
C. Old Meter Size / Type - VIM -0 , New Meter Size / Type MASTER
E. Type of work performed or findings:
11 I
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members: '
1 1. List materials used:
to
d .A
inspection: LL.
12. It you had art accident:incident while performing this request, did you report it? YES or z
1 3. Water Utilities meter ction: PASS or FAIL
1 -
14. How many trips to do task? 4 . _ ■ . i� 4, . ' 1
Signature a