2002_0316 WATER
Issued: 3 - 16 ' C " Finished: -fi„ ct Employee: (r u a ! Grid map:
Name: Address: J I 0 I \I I I \OC1
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
Bklow Ce- Date B. Valves B. Water Tower B. Line Locate
Re -Cer_ 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 Meters 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 -
Vehicle/Equipment Used
3. If Meter Change Out: Tait # Miles Hrs Equipment
A. Old Meter T re4 8 t y ti Reading j3(#
B. New Meter ; 2. G Z G .5 b 7 Reading [/
C. Old Meter Size.Trpe: ' 1 D New Meter Size:Type 2
E. Type of work performed or findings: p a s d s -4 •� R �t � f't
.1 .01 ' w . "7 /1 r✓.- t.' / G - 7 c •c
9. If mainline or deep service repair, describe type of pipe or service line and condition:
1 l `•f a- ,c _.: 3: 1, 0 Crew Members. (
1 . Lis: Nfreriais Used:
1 [f ; cuhad an ac ::de::. �.: :dent while performing this request. Did you ; ;:cr: ic? Yes or no
13. Water Utilities meter inception: pass or fail
14. How .many trips to do 'ask.? 2
Signature 7A"7'