2002_0430 WATER
Issued: `-Fi ss /oz. Finished Employee: Grid Map:
Name: I Address: 301 I,RKF Lc aT h
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Beak 3. Maintenance 4. Old
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: METJ&Z CLAN le_ 0 t)T
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 # CI ‘n, Reading 040 7
B. New Meter ;# 1 Reading l"
C. Old Meter Size / Type (2__ New Meter Size / Type 1 MAC its
E. Type of work performed or findings:
9. [f 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?
Signature