2002_0701 WATER
Issued: 7 / - ° Z- Finished: - 7 — 1 Employee: ITh XI Qt /� 7& Grid map:
Name: Address: / / 1 e-i4 - = X L4 r i
Phone Number. (HM) (WK):
Check for: Accuracy 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
S. 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 firs Equipment
A. Old Meter # crap z ei5? Reading 1 (03
B. New Meter # �il�lQ7�r Reading ,5
C. Old Meter SizerType: s hy ft D New Meter Si
E. Type of work performed or findings: defr a O
dJlu� 07i✓
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man- hours: Crew Members.
11. List Materials L'sed: /4-'e "IfEe''
12. If you had an accident 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 / is t 6/W n , - ,