2002_1119 WATER
Issued: 1— I 41° Ok Finished: Employee: ae'n ce,-/e,5' Grid Map:
Name: Address: 7 a 3 Qv S 0 a,14
Phone Number (I -LEI): (WK):
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:
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
If Meter Change Out:
A. Old Meter # '1 a . 3a.9 11 Reading / 8 o
B. New Meter # 3 15 1 1 pi Reading
C. Old Meter Size / Type Oa 4 f S l" New Meter Size / Type II M S S IY
E. Type of work performed or findings: •
9. It mainline or deep service rear. describe type of pipe or service tine and condition:
10. Man hours: Crew members:
11. List materials used:
12. If you had an accident/incident 'xhi1e performing this request, did you repor. it? YES or NO
13. a Water Utilities mete; inspection: PASS or FAIL
14. How many trips to do task?
ignature