2002_0814 WATER
Issued: ' / ° ` Finished: n
Employee: � C Grid Map:
Name: Address: (O/ 2 % .( l
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Rank 3. Maintenance 4. glik
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: 14, s s j 5 ef wet. kr" 7e0 I 14/z.e.441'
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 # 't/ 2 574 '3 C./ Reading l 1 9
B. New Meter # z11 4/43 Reading
C. Old Meter Size / Type � A 3 4/ New Meter Size / Type $ V4 57 A 77sx 3 �f
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 4 i 4 ;" Crew members: l
11. List materials used:
12. [t you had an accident ;incident while p orming this request, did you report it? YES or NO
1 3. Water Utilities meter inspection: ce0 or FAIL
14. How many trips to do task? 17-1-sex
Signature