2002_0814 WATER
Issued: 41 • I /4 ` OZ Finished Employee: f;#44ti Grid Map:
Name: Address: 1 4 4 iltrdellt4
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Emir 3. Maintenance 4. Old
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: M , 55 •Az q .5 t/'id n ;cir `741/' y4 '
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 # '11 Z Z I CO le. Reading 9 it 17
B. New Meter # Zee 4 1 / Le 62‘ Reading
C. Old Meter Size / Type C rX `f New Meter Size / Type ifiera 1 1 X >
E. Type of work performed or findings:
9. It mainline or deep service repa.r, describe type of pipe or service line and condition: A oC
`5a
10. Man hours: 2 " ^^;A - Crew members:
11. List materials used: E
e 0
U. 0 a i_
CO Z
1?. 1f you had an accident incident while • rforming this request, did you report it? YES or
13. Water Utilities meter inspection: PASS or FAIL _ a�
14. How many trips to do task? 1
Signature >-
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N O 2 ft o t x
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