2002_0313 i
WATER (f 4 t r ;/ - 1: i ;)
Issued: 3 15 Finished: 1 j e-d - Grid Map: /
n � Z Employee: o� s. a.
Name: `e1.U Rl� vt Y /1.t bC..lm�az) (IJ "° £A3
Address: � � — 6
Phone Number (HM): cm- 46 2. -- A' 9i (WIC): 2 4
Check For: Accuracy Test Meter Leak Check Water Pressure
E
Initial Meter Relocation Inspections Re -Read 0 LL a
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump
P A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate ;•1C
Re -Cert. Date C. Service Line C. Samples C. Tap 1s'
D. Hydrants D. Equipment D. Excavation
E. Safety x - i .t
L
S. Reason for Failure: A. Electrolysis B. New Construction C. Poor Installation D. Other y o 0
6, List of Safety Equipment at Site (if applicable):
0. 0 a
A. Barricades B. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: p[eaSe Check.- -� teat. Pp5Si biLa at-- (Mer k4
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 # 90O (L 3 to € Reading 147 1
B. New Meter # 2 t 2 q 1 3 Reading 1742r^
C. Old Meter Size / Type s / g / �~ �s' e� New Meter Size / Type C A • % 1��'
E. Type of work performed or findings:
/oz./ . " Zvi rheir/fit-‘ ( Ar c✓ra aCdr j G,,z cy e 46.4c
04 uv 74 //4 /J4"7 Isla t? 'r l ' eci:' D 4/ /
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: `f - s Crew members: ( 4),-/ - C rLuJ
1 1 . List materials used: c / y r d c , 5 ; coript n i ?4 4/1J7e'f/ ti/uc. J ?if ipic.
12. If you had an accidentiincident while performing this request, did you report it? YES or ti
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? 21
Signature