2002_1115 iNcl 40 Wi 11
WATER
Issued: it /15 Finished: Employee: ( l - _ Grid Map:
Name: Address: 503 , i l adtuu 0 OCL
Phone Number (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Reoair 3. Maintenance 4. Other
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date 3. 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: C-K VYr't' (pex date( rz)l
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
8. If Meter Chance Ou::
A. Old Meter = a 4 al-l9 Reading 1
B. New Meter = � J \ Si \ t4 Go Reading n
C. Old Meter Size / T voe Mq c 3 4 X 5 4 New Meter Size / Type /vLs -k —
3 4-X 3 7' c r
E. Type of work performed cr findings:
G Lt ti v1 e f7 J 1- -cp ; vvQ C vie_
• 9 fr mainline or deep :er•.ice re::.: describe type of pipe or service line and c :r.dition:
10. Man hours: Crew members:
11. List materials used:
l2. fr you had an accident :ncident .bile performing this request, did you repor ::? YES or NO
13. Water Ltilitie meter inspecticr._ PASS or FAIL
14. How many trips to do task? ► " /i
Signature