2002_0509 WATER
Issued: 5 1q1 Finished S iq /OZ Employee: Grid Map:
Name: Address: 30 CI L AKZL )0r
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re - Read
1. Backflow Insp. 2. $&INtit 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: A4640k. y e .
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 C t 1 71.1 01, Reading (4-7-1(o 1
B. New Meter # - 3 as ass/ Reading pf
C. Old Meter Size / Type 54 BAh-E New Meter Size / Type S - Nth
E. Type of work performed or findings:
A N
9. It mainline or deep service repair, describe type of pipe or service line and condition: °a ui
4
10. Man hours: Crew members: N E
o x
p ti U d LL
11. List materials used:
r
2 A
12. If you had an accident; incident •� hile performing this request, did you report it? YES or
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l 3. Water Utilities meter inspection: PASS or FAIL 3
14. How many trips to do task? ,, = 8 u
Signature n ° o
G 0 0 t m
a F- 0 a LL