2002_1119 WATER
Issued: I t — t 9 Finished: Employee: iCM Grid tap:
Name: Address: (� a1 J gv q, ■
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. 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
C If Meter Change Out:
A. Old Meter# 921k 7A 6 Reading I y a L / - (0
B. New Meter# 3 ( i 148 Reading
C. Old Meter Size / Type 1t-( S /k New Meter Size / Type /'A4 s 4 -
E. Type of work performed or findings:
9. [f mainline or deep service re.air. describe type of pipe or service line and condition:
10. Man hours: Crew members:
t 1. List materials used:
12. [f you had an accident/incident while performing this request, did you repot-. it? YES or NO
13. Water Utilities mete; inspection: PASS or FAIL
l4. How many trips to do task?
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