2002_0508 WATER
Issued: O Z Finished s f � /(Y7._ Employee: Grid Map:
Name: Address: 3(4r•! L- i.1 )6
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re - Read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Qtlxt
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: - C 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 # e i 1 22.Z0/ 4 Reading / 3 ?
B. New Meter # Q-0.62,3 o-R 7 Reading
C. Old Meter Size / Type =?A -'•,q New Meter Size / Type 1V1AS`Ta
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 chile 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