2002_0214 WATER /
Issued: Finished: Employee:C /�,.n(U Grid map:
Name: Address: 7 n-ec c O Gt) I a(lc
Phone Number: (FD .4) (WIC): _
Check for: Azcuracy 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: mP�e (1 h o t)5.P l)
7. If MeterlService 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
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter . 1 I3() 9' .,ZZ Reading (/ S, :01/
B. New Meter 7 ;L,(�( L.( qc Reading
C. Old Meter Size.Type: i'SAjr ip( �� D New Meter SizeiType
E. Type of work performed ortindings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Ma : -c � 5: 7 r `�� Crew Merr ers.
11. List Materials Used:
12. If you had an accident'.Lc :dent while performing this request. Did you report u? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many trips to do task? �'j�?
Signature JfdNAI / 7