2002_0625 WATER ��,
Issued: 25- 02 Finished: 6 / ) 7 /0 z Employee: a IGU tl Q. Grid Map: ,
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Name: Whr• bi I It rbl Address Pln \or)
Phone Number (HM): (WK):
(WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. gait 3. Maintenance 4. Otb
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: t'tdx Ogl Cheek C a &.I.4ra.
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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. Ii Meter Change Out:
A. Old Meter T /5q1001/e7 Reading t' t 1. 4
B. New Meter = ,;267 l 437 Reading (7
C. Old Meter Size / Type S � 1 C- New Meter Size / Type 5 /WAWA_
E. Type of work performed or Endings: Nc' -fin ckm Q Ova °f' fi -1-C3,- -�
9. It mainline or deep service :':a::. describe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date —� (D2 IPa° 2
10. Man hours: Crew members: To 1Ay joRtisbK1 From DEN (N6RmM
It. List materials used: Co./Dept . Will Co uT1(_tTIES
Phone # Phone #
Fax # Fax #
12. tt you had an accident,"incident x::tie 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? 7 .d 14 - • �'�
Signature