2002_0418 WATER 1
Issued: L4.-- ( a` Finished: Employee: c1/
\ c, C l k C. Grid Map:
Name: Address: 5 3 t\ o (I t v ` L►. i 11 S
Phone Number (HM): (WIC): �
Check For: Accuracy Test 7 Meter Leak 1,7 Check Water Pressure
Initial Meter Relocation Inspections Re -Read
1. Backflow Insp. 2. Emir 3. Maintenance 4. Oterer
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): ?c • 4 `�
A. Barricades B. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: LAC CA. MeA r f S r `ea K f _ / a n cc +'. V• c,
('^ er 8 V d . 13; it c h Sri y S v1 o,. e O w vuv r- 1 ys
U .S e. c, e__ — C re tv tY(, 0 0 4 . ? Cn D e .0 4 I N O 0--t
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 DOORKNOCKER
8. If Meter Change Out:
A. Old Meter # 75 , 0 6 -9<j Reading Vieggiing c RC 95
B. New Meter # c)) '/ 3 Reading
C. Old Meter Size / Type ,04_ New Meter Size / Type � "Ac.E-A
E. Type of work performed or findings: Hies 7 tqr- O i< 5
9. It mainline or deep service reps:, describe type of pipe or service line and condition: 111
a
10. Man hours: Crew members:
0
11. List materials used:
CD
CD
12. [t you had an accidenriincident while performing this request, did you report it? YES of
z
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
Signature To
0.