2002_0723 2 WATER
Issued: Finished: 7/Z3 Employee:CA, ) L Grid map:
Name: // Address: to Z p,vi p cc) r)
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. 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:
7. If Meter/Service Leak: Classify: - City : t/ Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorknocker -
VehiclefEquipment Used
8. If Meter Change Out: Unit # Miles Hrs Equipment
A. Old Meter # I J to 0 � ) b Reading 143 O �
t
B. New Meter tt .26 / /Z 75 Reading el
C. Old Meter Size:Type: 3/4 " D New Mper Size/Type 7/1/
E. Type of work performed or findings: i? 4'1 C P y i - y S c
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man - hours: 1' 5 Crew Members. -. £ H . FT
11. ListMater�]]als Used:
'NW PA—A-1, 3 )4 " rile{ -cfi 5e - tter 3/14 54),,ole hn
5 mat 1.1 w‘v r" Got t.4./ ;t% L: •
12. If you had an accident while performing th Post - it® Fax Note 7671 Date 81 Ipa °ges. oZ
To 1< Ay y 1 O t�. /fit From DE t [ �,' 1KG 1K /1 n /1 A
13. Water Utilities meter inspection: pass o Co. /Dept. OT �l 13 ILL' J Co. 1/Q T t I UI � 7 S l •�
} ` Phone # V � Phone #
14. How many trips to do task?
ZA Fax # Fax #
Signature