2002_0701 WATER /
Issued: 7 I ` D 2- Finished: - 7 - T Employee: ( 'l Grid map:
Name: Address: /3/ feae' / 12
Phone Number. (l f) (WI{):
Check for: Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. jtepair 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
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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 # ? /6253 ?? Reading
B. New Meter # 2 15 - /D/ 3 Ija�g /
C. Old Meter SizeiType: '1 le" D ew Meter Size/T/ ype -7tr
E. Type of work performed or findings: Cs)iAtr
iA / ex'
9. If If mainline or deep service repair, descnbe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials Used:
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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 7O�LLC e��SLs�