2002_0408 WATER
Issued: 4/ $ I 0 Z Finished: c-Il k /f)1 Employee: Grid map:
Name: Address: ,.2((, NI C- LA!.2b lV1F�AJ)btA
Phone Number: (HM) (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. Qj
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: IN \l✓4EP- di e 004-
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 -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # r Reading j ��37
B. New Meter # . . • r . Reading C'OC:0
C. Old Meter Size/Type: 5., D New Meter Size/Type 1hnxc4F12
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?
Signature eil.,( rtil�-