2002_0701 WAFER /
Issued: 7 — 1 0 t Finished: 7 -1 Employee: /; 1A (jj 1 Grid map:
Name: Address: / / / 2 r , 4 e A 9 ( - 4 1 - 1
Phone Number (HM) (WK):
Check for Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. glitz
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 # ?/0 ZSY((O Reading 2.4 S38
B. New Meter 4 3 15 / b Z . Reading y
C. Old Meter Size/Type: / D New Meter Size/Type .
E. Type of work performed or findings: rf /,dff ff ///P U'/ —
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: ��
1 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