2002_0508 WATER
Issued: 0 L Finished S (g oz,, Employee: Grid Map:
Name: Address: 353 LAIC€ .)hdD
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. kink 3. Maintenance 4. Qgbd
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: 1 2-1/ c t Tit -
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 # G J 1 2.2O / ? Reading 21 <} 1 n
B. New Meter ;# 6 5 Reading 0
C. Old Meter Size / Type New Meter Size / Type
E. Type of work performed or findings:
9. [f mainline or deep service reps: , describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. [t' you had an accidentincident 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?
Signature