2002_0819 WATER
Issued: Finished: 8^ 19 Employee: /,���v d Grid map:
Name: Address: /O F x52
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
r Initial meter relocation inspections Re -read
j 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. Equ pment 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:
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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 -
l Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # '1/lo 1 Reading
B. New Meter # �,' )1 I S 5 Readin 1 C �
C. Old Meter SizerI'ype: ft ivy j/8 D New Meter Size/Type
E. Type of work performed or fthdings:
j 9. If mainline or deep service repair, describe type of pipe or service line and condition:
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10. Man - hours: 1 Crew Members. 1r( 'I/
I
- 11. List Materials Used:
12. If you had an accident/Incident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pas or fail
14. How many trips to do task?
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