2002_0826 WATER
Issued: c t 2 ` 4Z Finished: Employee: f Grid Map:
Name: Address: 573 Pco--k
Phone Number (HM): (WK):
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Bask 3. Maintenance 4. Q
Backflow Insp. A. Main Line A. Pump A. Lane 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: A l a w rt B � t/3 `t'S o +' e ►
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 DOORXNOCKER
8. If Meter Change Out:
A. Old Meter 4 S 1 3 2 2 3 Reading / 5s tal 14 0
B. New Meter 4 3 'IC / S Reading __
C. Old Meter Size / Type f rP.4 • 4 im 3 f New Meter Size / Type 'ef 5 7gyYfe
E. Type of work performed or Endings:
9. If mainline or deep service re a:. describe type of pipe or service line and condition:
10. Man hours: r! Crew members:
11. List materials used:
12. If you had an accident'incident `:i - • orming this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
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