2002_0604 WATER
Issued: to 1 -1101. Finished: (o a2 Employee: Grid Map:
Name: Address: I aF' M c,J\ ttin u Z.
Phone Number (HM): (WK):
Check For Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2 . e$. • 3. Maintenance 4. Qt e
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: (JA-vv. e
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 # 89a /'150 Reading /C.2 <f)(4
B. New Meter # c /641 14,4b Reading 0
C. Old Meter Size / Type Q Q F �S tI �. New Meter Size / Type 4
a /t'I,(}S
E. Type of work performed or findings:
9. [f mainline or deep service rrpa:r, 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
l 3. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Signature