2002_0813 WA TER
Issued: �-i 3 -D i�Finished: Employee: A Grid map:
Name: Address: aO Iv k 0 cAx tp i t`ul
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 Cen. 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. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
C>f Meter Cha ge Out: Unit # Miles Hrs Equipment
A. Old Meter # a.5,3 Col Reading 1 5 9 G L1
B. New Meter # 315 1 335 Reading -'9—
C. Old Meter Size,Type: Qygdyyr,r 5/W D New Meter SizeiType ry s }r -5 /'
E. Type of work performed or faidings:
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:
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IN
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12. If you had a:: ac: :den. Incident while performing Phone # Phone # 1 G
Fax # Fax #
13. Water Utili ties meter inspection: pass
14. How many :rips to do task?
Signature V