2002_0813 WATE
Issued: g — 13-09-Finished: Employee: Grid map:
Name: Address: 04 O O (V t p C 1 . 4 % via k r�
Phone Number: (HM) (WK)
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
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. 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. Waver Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
0 If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # y 1 L a 5 3 K Reading a 1 5 o a
B. New Meter # 3/5 / 3µo Reading -$--
C. Old Meter Size.Type: dqqe,r 5 / e D New Meter Size /Type M a S *e r -SA?
E. Type of work performed or fln'dings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materaa Used:
12. if you had an acr:den. incident while performing this request. Did you repot it? Yes or no
13. Water Util:::es meter inspection: pass or fail
14. How many :rips to do task?
Signature _4 , 1 14'