2002_0403 / WATER
Issued: 4/3/0 D L Finished: Il / .3 /t) Z Employee: Grid map:
Name: l(( Address: 17 / 141 G-l4L.4!tJt) M EAi ,
Phone Number: (HM) (WK):
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. ¢a ckflow Insp. 2. Repaii 3. Maintenance 4. Qtha
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: j'1 Cr C e_ 4t-t-
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 Doorlmocker -
Vehicle/Equipment Used
8. If Meter Change Out Unit # Miles Hrs Equipment
A. Old Meter # -2 0 3 % 1 Reading (;5 cD /
B. New Meter # E ) I )C7$ Reading esevo
C. Old Meter Size/ Type: S/' riAs D New Meter Size/Type Mils-r 12_
E. Type of work performed o7 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 7il/IG.<1r l/)3