2002_0507 •
WATER
Issued: 5/ _ Finished 5 /1 /0 Employee: Grid Map:
Name: Address: .30s Lod< b 7 o n ii)
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re - Read
1. Backflow Insp. 2. $a& 3. Maintenance 4. Qt
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: I e4ei _ N?e od -4
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 # q / ? Z) ( Reading (01 2--
B. New Meter # �!! J Reading scO
C. Old Meter Size / Type f�" 7'GZQct S /t) A) New Meter Size / Type 5 MAS1
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:
l ?. 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? �i°Lip /47
Signature