2002_0507 WATER •
Issued: 61 e. Finished Employee: Grid Map:
Name: Address: 3?0 tU.C' C J
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Inso. 2. Balk 3. M= 4. Qt et
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: « J Anx� Q, MeATIL
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. ?J - 7 7 - Reading /
New Meter # ) 3 Reading 0
C. Old Meter Size / Type f PReosino New Meter Size / Type Ma64 _—
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
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Signature