2002_0226 WATER �-� �,
Issued: 2- 21- OZ Finished: 2 —z / d � Employee: _k�?:t �' ft n f - Grid Map:
Name: sk.-a,l ? (<l L lS Address: .259 L()ifd.tn . Fh I (r OA
Phone Number (HM): era- 593 - 43 (wig: .lI
Check For. Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Rank 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: Please 2he(_ -6r C @ /►yea r I�Ai
IRl r� Ckor be let extStfr er knew What ( )hat (etl - (nct .
7. If Meter / Service Leak, Classify: City Customer
A. Water Loss (estimate): GPM Fire Plug Flushing Total Gallons
B. Was Water Metered: NO
C. Was Customer Notified: VERBALLY DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # Vg /.3 Z / 7 Reading / L 3 7 J 3
B. New Meter ;# 2 (► 4 1 J L. Reading -e
C. Old Meter Size / Type -sit P e New Meter Size / Type 1..A . ) fi
E. Type of work performed or findings: /, c
yP P� g rum i S O nl C :17 S. le
9. If mainline or deep service repair, describe type of pipe or service line and condition: °Q Z W
n
tv
10. Man hours: 1 / Crew members: W14 iG ( N s c
m e o L m
11. List materials used: /) e ti f 1 G- ` 1 .( ° u. " a u_
`rte- 2
J
2 —I
12. If you had an accident/incident •vhile pO'orm'. g this request, did you report it? YES or a,
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io,�:
l3. Water Utilities meter inspect AS or FAIL /,� �� � X
14. How many traps to do task? z `.1,- a
Signature y e o
x
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