2002_0701 •
WATER
Issued: 7 -/ "0 Finished: 7 Employee: %/ i° G( Grid map:
Name: Address: /IV Me4e /(t.c rJ
Phone Number ( i) (WK):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ac • ow Insp. 2. impair 3. Maintenance 4. Q
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 -
Vehicle/Equipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # 9 12 LO/ L 7 Reading ;6
B. New Meter # ?/ S /017 &eading /
C. Old Meter SizeiType: /4' re D ew Meter Sieype /J l�
E. Type of work performed or findings: ILO /�fP / c'' l'44°
9. If mainline or deep service repair, describe type of pipe or service line and condition:
yt:
10. Man- hours: Crew Members.
11. List Materials Used:
rl e°3 ,t4 7P/ Y4 /9Q / /to o
12. If you had an accidenclncident 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 (,.l%cR-