2002_1119 WATER
11 t 4 a. Finished: Employee: Be A'\ CeryeS Grid Map:
Name: Address: (o E4v q,l l
Phone Number (KM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Inso. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dace B. Valves B. Water Tower B. Line Locate
Re -Cert. Dace 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 Custo
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
63 If Meter Change Out:
A. Old Meter # O 1 o0 61 K Reading / 7 7 1 g
B. New Meter # 315 1 1 3 Reading
C. Old Meter Size / Type f 3 ,5 e- c s/r New Meter Size / Type ( / S -)-er 54
E. Type of work performed or findings:
9. If mainline or deep service re,air, describe type of pipe or service line and :ondition:
10. Man hours: Crew members:
11. List materials used:
12. [f you had an accident/incident ‘.vhile performing this request, did you repor' it? YES or NO
l3. Water Utilities mete inspection: PASS or FAIL
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14. How many trips to do task?
Sign . re