2002_0507 WATER
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Issued: _ S / -7 /0 L Finished 51 -- 1) 0 Z Employee: Grid Map:
Name: Address: 31(0 LAke Loo b
Phone Number (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &Mir 3. M 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: C. -64, cte K- -{-
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 # O3 'i Reading irc�l
B. New Meter # 3 a2C>.i51i Reading X
C. Old Meter Size / Type S � R� t . .s SAJ New Meter Size / Type MAS-1142..
E. Type of work performed or findings:
l`-
V cn
1.0
9. It mainline or deep service repair, describe type of pipe or service line and condition: LEL
C4
I t ,
E
l 0. Man hours: Crew members: ° 6 a
11. List materials used:
1? [t you had an accident incident while performing this request, did you report it? YES or o
z 4 pi
13. Water Utilities meter inspection: PASS or FAIL n
14. How many trips to do task? fw,f c,
Signature �' e g
l a i- 0 a LL