2002_0725 WATER
Issued: Finished: *At- Employee: Ni Grid map:
Name: Address: 1/4.- Aftxtow We /
Phone Number: (HM) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backtlow 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. Equpment 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 Mete: = 1 916Z..53 4 9 3 Reading /I /; 2kt
B. New Meter = 3f) 3 92 Reading U
C. Old Meter Size.Type: /3 t, 7 E' D New Meter Size/Type AdriVtip A1J . g
E. Type of work performed or findings:
Carat` 0j". 4/ItIM
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 an acc;den: Incident 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 task?
Signature ((AU
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