2002_0508 WATER
I Issued: .5 ' I c� Finished 5 IBS l a L Employee: Grid Map:
Name: Address: S2 1 on
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. $O& 3. Maintenance 4. Old
Back low Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent. 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: C:
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 / Z7 7 c9 /7 Reading /
B. New Meter # 3 a- g (p Reading
C. Old Meter Size / Type 56 POGO a c i ovU New Meter Size / Type 5 tr - tiM3 Q.
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