2002_0814 WATER
Issued: « /' 02-- Finished f Employee: F Grid Map:
Name: Address: -0 i• 75 Pdafit teal
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp, 2. BM& 3. M_ 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: Al . 5 5 � of a�C `t t, er for m i -
J v
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
8. If Meter Change Out:
A. Old Meter # q/62 ZS Z2 Reading /o fQ q 4
B. New Meter ago 4 ((Cc 7 Reading -6
C. Old Meter Size / Type 5 78 x �f New Meter Size / Type 41,451k7e 5 *K 3 �j /
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Z Crew members: 1
l 1. List materials used:
t?. If you had an accident, incident x wile arming this request, did you report it? YES or NO
13. Water Utilities meter inspection: or FAIL
14. How many trips to do task?
Si cure