2002_0701 WAFER
Issued: 7-1 Finished: . 7 - 5 -4 Z Employee: Dc4D fr � Grid-map:
Name: Address: / Z /77;zr4_1z---
Phone Number: (HM) (W):
Check for: Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspections Re -read
1. $ackflow Insp. 2. Repair 3. Maintenance 4. Qther
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:
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 7 9 i Dqp, I)`73 Reading / 7 %/j
B. New Meter # qb' ii / Reading / 7
C. Old Meter Size/Type: I ; (1 t: h D New Meter SizefType i (di
E. Type of work performed or findings: rr.0-U ZL oAcl,
n P Li Ov
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: S kd-
1?. If you had an accidentlncident while performing this request. Did you report it? Yes or no
13. Water Utilities meter inspection: pass or fail
14. How many nips to do task?
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Signature V" J t/ - 1'w