St Joseph-WO020716Issued: 1- [~-' 0~. Finished:
Phone Numbe-r (~): - 14- gq6--
Check For: Accuracy Test Meter Leak
Initial Meter Relocation Inspections
1. Backflow Insp.
Backflow Insp.
Bkflow Cert. Date
Re-Cert. Date
WATER
Employee: ~ Grid Map:
Check Water Pressure
Re-Read
2. Repair 3. Maintenance 4. Other
A. Main Line A. Pump A. Line Locate
B. Valves B. Water Tower B. Line Locate
C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D. Excavation
E. Safety
5. Reason for Failure: A. Electxolysis 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: ~.t~d[~l/~, q-'['~'O~
7. If Meter / Service Leak, Classify:
City
A. Water Loss (estimate): GPM __
B. Was Water Metered:
C. Was Customer Notified:
If Meter Change Out:
A. Old Meter #
B. New Meter #
C. Old Meter Size / Type
E. Type of work performed or findings:
Fire Plug Flushing
YES NO
VERBALLY
Customer
Total Gallons
D~R~OC~R
Reading
Reading
New Meter Size / Type
/
9. If mainline or deep service repair, describe type of pipe or service line and conditioh:
10. Man hours:
11. List materials used:
Crew members:
12. If you had an accident/incident while performing this request, did you report it?
13. Water Utilities meter inspection: PASS or FAIL
14. How many trips to do task?
YES
Signature
or NO