2002_0701 WATER r /,/
Issued: 7-1 _0 Z Finished 7 Employee: / i ,I "1 L O Grid map:
Name: Address: f Z Z Y
Phone Number: (HM) (WK):
Check for: Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Mak 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 -
Vehicle/Equipment Used
8. If Meter Change Out: q Unit # Miles Hrs Equipment
A. Old Meter 7 9/' 6 2 Reading / r. P57
B. New Meter 4 7 /57.0)y Reading 5
C. Old Meter SizeiType: Icy D New i eter Size/ Type 3 /■ e
E. Type of work performed or findings: r //1[P(' e/d
y�c ,' i
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials Used:
/f(C fr . // � g ,er /l /L �
12. If you had an accident1ncident 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 Pilt/k..