2002_0626 WATER //
Issued: Finished: Employee: f12C /E O Grid map:
Name: Address: /02 ' 41,91)Z L C F
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. Equpment 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:
( 6.nirif 0U+
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: % 6 Unit # Miles Hrs Equipment
A. Old Meter # l L� /' Reading 1 L � g l `t
B. New Meter # / 5 I D & Reading [ '
C. C. Old Meter Size /Type: /3 (.c P. V' D New Meter Size/Type /4 /1' / z 5/ -
E. Type of work performed or find
9. If mainline or deep service repair, describe type of pipe or service line and condition:
79 ,j
N „S
10. Man- hours: / Crew Members. C) - /
11. List Materials Used: 6"2� I # o 7
Post -it® Fax Note 7671 Date pagf es
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Co./Dept. 'l wiz 131114 t)6 Co. UT I T I ES
12. If you had an accident'Incident while performing t Phone # X11 (� Phone #
Fax # Fax #
13. Water Utilities meter inspection:
14. How many trips to do task? )
Signature jr 1 /`z