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2002_0912 raic cr 51, - s . t' V / �iv•h i WATER �� Issued: �I I la I l.d- II Finished: , (� I Employee: U't an kl Grid Map: Name: Orr. 7I llYl Vatbr -i Address: 4 ©4 eirz,,t Du Phone Number (I -LNI): (WK): J Check For: Accuracy Test Meter Leak Check Water Pressure Initial Meter Relocation Inspections Re -Read 1. Backflow Insp. 2. Repair 3. Maintenance 4. Other 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: 02,01 UV\'I"Y. 5, Pat 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 = 1 95;2533 Readin /2--- B. New Meter # ei 99155 Reading 0 C. Old Meter Size / Type New Meter Size / Type / 1 " 1.2-4- q r E. Type of work performed cr findings: P/441✓G4 - © G/7 / 'c / r/L 2 7) 7 TZ j7 / /d7 9 It mainline or deep ser•.ice describe type of pipe or service line and condition: / / [0.:vlan hours: Crew members: 11. List materials used: 12. It you had an accidenuincider :.chile performing this request, did you report it? YES or NO 13. Water Utilities meter inspection: PASS or FALL 14. How many trips to do task? Signature