2002_0402 WATER
Issued: 4_44Z____ Finished: LI /Z/0 Z. Employee: Grid map:
Name: Address: / 55 III 644,41v0 McA-llit a
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Me;
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: merat e &4N 7e (k) 1
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 # 04030S Reading d R
B. New Meter # -,,IS' Ja ,38 Reading 0066
C. Old Meter Size/Type: M ASSI - a D New Meter Size/Type St MgC-TFQ
E. Type of work performed 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 dytf , e l / .1.4 /--- 00