2002_0901 WATER
Issued: CI .1. z Finished: L Employee: F Grid Map:
Name:. Address: 2 / q A 1 .4o /NV
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. Kg&
Backtlow 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
�yD. Lights / E. Other
REQUEST FOR SERVICES: �l e.� l -3`
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 DOORKYi OCKER
8. If Meter Change Out:
A. Old Meter # g413 Z 5-8 Reading 2- 0 S 1 F
B. New Meter # 2 320 Re 6 Reading -e- /
C. Old Meter Size / Type �'��� Sroy� �`� �. ' New Meter Size / Type 4604' �/r' '�
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
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10. Man hours: t S Crew members:
11. List materials used:
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l ?. [f you had an accident, incident while .. . ing this request, did you repot: it? YES or 2 -f.
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13. Water Utilities meter inspection: PASS or FAIL. v '
14. How many trips to do task? ( - z
Sign e n 3
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