2002_0507 WATER
Issued: 5/7 w Z— Finished S J 710 2-- Employee: Grid Map:
Name: Address: / h,A1Cr" 1J ' 1>
Phone Number (HM): (WK): _
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &ERZ 3. Maintenance 4. Othet
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: ,mod (11.6,A1 e 001
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 T Q/ Z-Z.1 - 7,Z- Reading / 3D3S
B. New Meter # 0--3aa as 1 Reading clf
C. Old Meter Size / Type New 6 SO N New Meter Size / Type � Iyl AS`[! 2
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:
11. List materials used:
12. If you had an accidentincident while performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL //2�
j 14. How many trips to do task.
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Signature