2002_0508 I WATER
Issued: 5/ $ I Finished: 51 Employee: Grid Map:
Name: t Address: CE X.01
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &MIX 3. Maintenance 4. Qtlig
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 414.10 o M t 54S-' .
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 1 ZZ.. i 7 Reading / 3
B. New Meter # .P-3.2e) Reading cd
C. Old Meter Size / Type New Meter Size / Type S NU
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:
I 1. List materials used:
12. If you had an accident; incident While performing this request, did you report it? YES or NO
l3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Signature