2002_0422 •
WATER
Issued: , � Z ?in I. Finished glee /01. Employee: v � Grid Map:
Name: Address: hr��'�F VC 1) Lc) C Y
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $tea' 3. Maintenance 4. Otete"
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 D. Lights E. Other
REQUEST FOR SERVICES: I &"1 p ()OT
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 1 00 bS Reading %i 55(
B. New Meter L) 1 y (0 0 Reading
C. Old Meter Size / Type . New Meter Size / Type Meta
E. Type of work performed or findings:
9. Ef 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 accideno"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? [ / 4 -4
Signature