2002_0606 WATER -
Issued: - !O Z Finished: - 2 r Z Em Grid Map:
/ ,m /_' - . _�_ - Address: 07
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. Cone � C. Tape D. Lights E. Other
REQUEST FOR SERVICES: "' d ... . ' - frA_ m._ - ' ---
J — ;
0/ ' .., .
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 qz2 33o Reading e BSI'
B. New Meter T _ e2//) Rfgr Reading 75
C. Old Meter Size / Type ✓ d New Meter Size / Type
E. Type of work performed or findings: 0 �
9. If mainline or deep service repair, describe type of pipe or service line and condition: _
Post -it® Fax Note 7671 Date 6-12_02 Ipao 2,
10. Man hours: Crew members: _ To 1(m .rjp1{0 9)14 From DELI I%
Y�
Co. /Dept. i ► K. 9i LU Co. 'ATI LIT( E5
11. List materials used:
Phone # Phone #
Fax # Fax #
12. If you had an accident/incident while performing this request, did you report it? Y S or NO
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task ?' ��f ---
Signature