2002_0430 WATER
Issued: 1 -11.10 (0?. Finished: , 4 4/30 /02, Employee: Grid Map:
Name: Address: 1. AVF,1 fl(th
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
L Backflow Insp. 2. &Mir 3. Maintenance 4. Otbq
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: f4e7 L 44 y C o (
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/ Z Zi (o Pi i Reading ///q7.
B. New Meter i# 03aO (Z- Reading 0
C. Old Meter Size / Type 51 [ EIL New Meter Size / Type 5 5i n--
E. Type of work performed or findings:
f
r 41 E 7
2
9. If mainline or deep service repair, describe type of pipe or service line and condition: .a J
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Crew members: °
10. Man hours: o LL a co
i 1. List materials used: 2
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1 2. If you had an accidents incident while performing this request, did you report it? YES or o = t
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13. Water Utilities meter inspection: PASS or FAIL 7 t t, 0 I a
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14. How many trips to do task? . o
Signature o 0 o t
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