2002_0726 WATER
Issued: Finished: Employee: 174rU 9 Roe Grid map:
Name: Address: 0( 11 '/ - 461900 Viet()
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation i=.spec: ions Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkllow 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. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter = IYZ:N Reading
B. New Meter .= 21 2 -4 Reading 2 /
C. Old Meter Size.Type: b New Meter Size/Type A-6441 114
E. Type of work performed or findings:
feAfeL / c liAt e" 7 o 4WirieR T /1" t-
9. If mainline or deep se: repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members. .
11. List Materials Used:
12. If you had an accident .ncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do ask?
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Signature 1 ,:,/ IL a,