2002_0604 WATER
Issued: �l4�' Finished: (v (U 6 2 Employee: Grid Ma
P:
Name: Address: J o 1 MMA Yt►u Q
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. 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: ME-d -mot.. e LL x r
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 At q 0 Skfdn Reading (7 89,34
B. New Meter # ,-=1(0 `f I (AO Reading ( 5
C. Old Meter Size / Type T P,q - New Meter Size / Type
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: Crew members:
11. List materials used:
12. If you had an accident, incident while performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task? ( •44 ,z, a
Signature