2002_0312 WATER
Issued: 3. Ia ' (Q Finished Employee: '- 0 - 1 Cr Grid Map:
Name: Address: 1 f `)/ t /(' /l-.r
Phone Number (HM): (WK):
Check For: Accuracy Test X Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. &ink 3. Maintenance 4. Qlhs
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. Con C. Tape D. Li is E. Other
REQUEST FOR SERVICES: Q "1-6 I, o J Y
7. If Meter / Service Leak, Classify: City Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons i
B. Was Water Metered: YES NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # ? /p2) Reading 9 ?,5
B. New Meter # a(3 7 X Reading 4,14111109 2
C. Old Meter Size / Type New Meter Size / Type
E. Type of work performed or findings: _/, _ �j _ _ &` 1 . _ A 1
A. ei
9. If mainline or deep service repair, describe type of pipe or service line and condition: L
,o r - rr
10. Man hours: Crew members: i E 0 x
o x
0 u`. 0 a u_
1 1. List materials used:
12. If you had an accidem'incident • x hi1e performing this request, did you report it? YES or w
_s �
z
13. Water Utilities meter inspection: PASS or FAIL / /� c) 3
u
14. How many trips to do task? F,
Signature H o o X
a , � 0 a u_