2002_0508 •
WATER
Issued: Finished 5 Employee: Grid Map:
Name: Address: 3(.41 G^ 4teittDExI
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &Mk 3. Maintenance 4. gad
Backf low 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 lI E. Other
REQUEST FOR SERVICES: �- C 1I4.NCrQ
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 # -1 O SR 13 Z Reading 1.' 79(,
B. New Meter # Reading C(
C. Old Meter Size / Type l 6-F t New Meter Size / Type ; MXTE
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:
1 1. List materials used:
12. It' 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? 1 / - . _AA/
Ter
Signature