2002_0911 WATER
Issue,: (taco 2 Finished Employee:. Fra.- Grid Map:
Name: Address: 5 79 ' 14)66 1 h ur S/t
Phone Number (HM): (WK)
Check For: Accuracy Test Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. e$�a' 3. Maintenance 4. Qtl�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:
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 i DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # OS / 3 (.1O 3 `t Reading o 4 0 "1 p
B. New Meter T 31C1 3 l el Reading
C. Old Meter Size / Type B` 5 7q ) New New Meter Size / Type x der ' 3 4
E. Type of work performed or findings: 13v sifed cure slop - Ero k e 4..in• o 1P
9. If mainline or deep service reps:; describe type of pipe or service line and condition:
10. Man hours: 2 Crew members:
// 1 ... l 3 ') co• 4 er /L
11. List materials used: -a) c�J/ s'>;- u Ccz �'i - 4 J
3 %y CoArres s an coed, iti
12. [(you had an accident, incident while . orming this reque
13. Water Utilities meter inspection: PASS or FA1 Post- it ® ,, Fax
�( Note `` 7671 Date 4_11... )) (pa
To Kt7 jitNS�� From 1) 131
14. How many trips to do task? 1' Co. /Dept. Co.
�- BiLr.INC� UTILlTitS
Phone # Phone #
Fax # Fax #