2002_0806 WATER
Issued: $ (o t»F'inished: Employee: k.1 — k Grid map:
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Name: Address: , 1 3 l 1 i 1 c..' \\ e_
Phone Number: (HM) (WK):
Check for: Accrracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. Backflow Insp. 2. Repair 3. Maintenance 4. Other
Backflow Ins:. 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. Equ pment 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. Wa :er Loss (estimate): GPM Fire plug flushing • Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
Vehicle/Equipment Used
@If Meter Cha_ge Out: LL Unit # Miles Hrs Equipment
A. Old Meter # 8 55 $ 6 q (v Reading G45.5 ''T
B. New Meter # g /5/ a 13 Readjng G for'
C. Old Meter Size.Type: Go■d e!' 5 /g D New Meter Size/Type (V\a *eC'
E. Type of work performed or fi
9. If mainline o: 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 accident Incident while performing this request. Did you report it? Yes or no
13. Water Uuli: :es meter inspection: pass or fail
14. How many yips to do task?
Signature V I
1,