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2002_0912 WATER Issued: Cl la 10g- Finished: Employee: Franki e.- Grid Map: Name: lA)fr l./t l II i t Address: _ ) / . 1 U( Phone Number (KM): (� / (WK): Check For: Accuracy Test ✓ Meter Leak Check Water Pressure Initial Meter Relocation Inspections Re -Read 1. Backflow Insp. 2. Re.Dair 3. Maintenance 4. Other Backflow Insp. A. Main Line A. Pump A. Line Locate Bkflow Cert. Date 3. 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: plexp ' { t UVy0rte attr off _ NcT tic( ri back cm: 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: i A. Old MeterT n 1 � ��� s t5 Reading N?F •0 0 B. New Meter # 14, q 9 �J f -rG 1,2”k9.5 r Reading 0 C. Old Meter Size / Type /PDC L 7g New Meter Size / Type /I7 x syr E. Type of work performed er findings: C// . - ©64 -lzk- / IW 1-0 7 25, 9 It mainline or deep ser. ice re_,:r, describe type of pipe or service line and condition: 10. Man hours: Crew members: 11. List materials used: 12. It you had an accideneincident .chile 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? Signature