2002_0813 WATER
Issued: 3"'" I 3 OO finished: Employee: Q/o Grid map:
Name: Address: a a. " M D G v�c� b ��
Phone Number: (HM) (WK) �1
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
Bk low Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cen. 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. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
®If Meter Cha ge Out: tint # Miles Hrs Equipment
A. Old Meter #116a55 S 1 Reading a 0 (o +(
B. New Meter # 315 t 33 y- Reading
C. Old Meter Size.Twe: C3�,cj, e,( 5/k D New Meter Size/Type (' +cr
E. Type of work performed or dings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials Used:
12. If you had a:: ac :ides.: Incident while performing this request. Did you report it? Yes or no
13. Water Uti1 :: :es meter inspection: pass or fail
'R
14. How many :rips to do task?
Signature