2002_0815 WATER
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Issued: � . --Finis d. _ Employee: 7..si Grid Max _________
Name: l,� �Z�C,Q�- Address: 7Cv 7 / `'cac,
Phone Number (-LM): (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: / i �o�p A6 S 7f' _, �� (1 U G C ! -r1L2- i •
13 b47Y sse5 -a . fi 4/ g• 2(e •4Z
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 # 'Zto- 'z(e S 7 e Reading (00 1 €€ 2
B. New Meter .. - T / 20228 Reading 0 11 CO S
C. Old Meter Size / Type a,s r 2 j New Meter Size / Type Atta..s r 2
E. Type of work performed or findings: (Vii P e t-- v'tom s f ck, ) im-e ..e t. ec/ -
C.3O
9. It mainline or deep seer ce repair, describe type of pipe or service line and condition:
10. Man hours: W it h> Crew members: 2 irp.N`c ` Q ny
1 I
11. List materials used:
12. It you had an acc :den:ncident chile •e orming this request, did you report it? YES or NO
13. Water Utilities meter inspection: PASS or FAIL / �
14. How many tips to do task? Z *
Signanre