2002_0918 r t u l * Ua lv r 'i
@ LOtV ��
WATER
Issued: 1 Finished: Employee: Fran Icie, Grid Map:
Name: UCUO r i i ( uYIT bill t Address: 44q Sim K u 11
Phone Number (I-D.1): / (WK):
Check For: Accuracy Test ✓ Meter Leak Check Water Pressure
Initial Meter Relocation Inspections Re -Read
I. 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: Pl05e ptia rylfir ( St
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 = i" Z s 1 0 Reading Z I 00
B. New Meter = Z 3 2 -0 l 5-3 Reading -'�—
C. Old Meter Size / Type icy +r 7V 3/p' / New Meter Size / Type Ofix . 1
S7 (/
E. Type of work performed or findings: ,34 d1 c *+erg 6 t . M l� f" o a/. q ° lT `O F 1.
9 If mainline or deep se: re :.:r, describe type of pipe or service line and condition:
10. Man hours: Crew members:
I 1. List materials used:
l2. [f you had an accident :incident this request, did you repot it? YES or NO
l3. Water L`tilitie� meter inspection: PASS or FAIL
[4. How many trips to do task? 1
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