2002_0701 WATER /�
Issued: 7-/ Finished: , 7-/ Employee: /9C� L°1 " 4 < / 6.- Grid map:
Name: Address: /0 7 /t
Phone Number (ILM) (WK):
Check for: Accuracy test Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow t. 2. Rear 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 4 '77 62 2 S 1 1 to 7 Reading Z b f 7
B. New Meter 4 /� i ota R
C. Old Meter Sizu fr( -At D New Meter Size/type fy S ire
E. Type of work performed or findings: r�,k -Ceti n1a w� — �f' 4
v. e
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: ] n
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 ) 4(..- //t 4aeliZ