2002_1205 WATER
Issued: la 5 _O g Finished: Employee: 1 i Ce..r I4 Grid map:
Name: Address: t 13 !M eoj Uc M C rea ✓`
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 Insp. 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. 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:
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 -
VehiclefEquipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # a3 ci 9 5 Reading 9 tog M-
B. New Meter # Reading -e' .
C. Old Meter Size :Type: 5 ' ( s r D New Meter Size/Type 5/A-- / 5
E. Type of work performed or findings: CZ i ce S " Ot, f LA/q 4
we. were- 40 -1-ti ,rn Off LA/el - e Crie r co .-lA
,no+ lO + 1 L O 4)P C.-et v s e- / • t' C le S k a � w �,S ' - - c a et
9.
P cot - ,wt - 4 C a 4, ! {a • p`e.n • C g( r 0 5'6 r.
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10. Man- hours: Crew Members. 93e �ll rew 1 ��n✓+��
n Ce .. je S rvk rs� c (.) �� K
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11. List Materials Used:
12. If you had an accidentincident 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 , ,,�/ /7 V — I