2002_0629 WATER �
Issued: L'o' 2q - 02.. /1W Finished: Employee: / � 5/0 Grid Map:
Name: Address: `76 to H I Cd / /1
Phone Number (HM): (WK):
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Inso. 2. Kozak 3. Maintenance 4. Qtbg
Backflow Insp. A. Main Lame 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. 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: It errs e /f IC r , '
7. If Meter / Service Leak, Classify: City ` Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: YES NO i—
C. Was Customer Notified: VERBALLY I/ DOORKNOCKER
8. If Meter Change Out: dd
A. Old Meter R ' 1, 0 G 0 . Reading 3 1'
B. New Meter = 3 15/4 _ � Reading 0
C. Old Meter Size / Type Fm4 �X � New Meter Size / Type "4 'ix Ai
E. Type of work performed or Endings:
9. (t mainline or deep service re.a_. describe type of pipe or service line and condition:
Post -it® Fax Note 7671 Date 7 402 Ipag s
10. Man hours: Crew members: _ To (/wy Jo 30 14 From pthi 1 3t R
l 1. List materials used: Co. /Dept. • SI IA- I 1J16 Co. UTILITIES
Phone # Phone #
Fax # Fax #
12. ft you had an accLdent incident A title performing this request, did yo report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL /
14. How many trips to do task? . _All/m1■101
Si_, r. lure