2000_0210 WATER
Issued: /0 /0 Finished 9/) l Ernploye Grid map:
Name: ( Address:
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 Lass. A. Main Line A. Pump A. Line Locate
Bkilow 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 Ex avation
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
3. If Meter Change Out: Unit 4 Miles Hrs Equipment
A. Old. Meter 4 5 S 2 9 Reading »(' '
B. New Meter 6 t &16 Rea in = -
C. Old Meter Size:Type: e4 i o n SA' X / 1 D New Meter Sizeirype/foiy{w / ' A '
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Crew Members. L.
11. List Mate ^as Used:
1 If you had an accidentL cident 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 314,1