2002_0507 ( WATER
Issued: 51 7 /o Z Finished: 5/7 / o 2— Employee: 31a Grid Map:
Name: Address: isit L AK P, On
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Bm& 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: t (in Nc e C7r 3-a- --
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 # qtazkoct..3 Reading I (v8a'
B. New Meter # 25 i Reading 9
C. Old Meter Size / Type .i Pkoi c 5 i no New Meter Size / Type MA5 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 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? ".141,,,,_ ".141,,,,_ .
Signature