2002_0508 WATER
Issued: 5-1q,,, Finished S J g /OL Employee: Grid Map:
Name: Address: 3 7 1 A
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. E,gir 3. Maintenance 4. Qllik
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'.h e. nn. x .
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 9 l 2 Z 1) --S Reading /234, 7
B. New Meter ;# Reading
C. Old Meter Size / Type BPI FR %g New Meter Size / Type
E. Type of work performed or findings:
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9. It mainline or deep service repair, describe type of pipe or service line and condition: -
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a, E
10. Man hours: Crew members:
0
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11. List materials used:
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12. It you had an accidenr incident while performing this request, did you report it? YES or z°
13. Water Utilities meter inspection: PASS or FAIL
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14. How many trips to do task? _ .. d A 1; t . �. . o
Signature a 1- 0 LL