2002_0228 •
WATER
Issued: Finished: ?- 0 lie Employee: Grid map:
Name: Address: OD, m j�If d'e LA- C d ,
Phone Number: (KM) (WK): u
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
B:ctlow 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: nie 7 l e v e J I C& iuge Oat -
7. If Meter, Service Leak: Classify: - City: Customer
A. Water Loss (escalate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment used
3. If Me :er Change Out: Unit 4 Miles Hrs Equipment
A. Oid 1j Meter l72 b6/ Reading %2 /( 7 6 c)
B. New Meter 4 a y) u 1 (o Reading �'
C. Old Meter Size-Tyne: 1/‘ eigelteir D New Meter Size:Type
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man --c_:. �i�5 Crew Members. /
11. List Materials Used:
l?. [f you ,ad an accident .:dent while performing this request. Did you . ;cr. it? Yes or ao
13. Water Utilities meter inspection: �ass or fail
14. How many trips to do ask?
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Signature : A -