2002_0804 WATER �✓ _
Issued: R(4102\ Fini hed: Employee: 1"� `dl'lkt Grid Map:
Name: Wilf • 131( ti a f l 4 3 o h i v a r 1 z Address: (40 L I rd1S
Phone Number (ILM): (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. Cones C. Tape D. Lights E. Other
REQUEST FOR SERVICES: Wei( *l.u
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 # 2 5-12 9/ 4! Reading tP®OCO 12
B. New Meter # 2!0 SSq 41k °/ Reading �--
C. Old Meter Size / Type $ 1 �f4 New Meter Size / Type /114ST R AK
E. Type of work performed or findings:
9. If mainline or deep service repair, describe type of pipe or service line and condition:
10. Man hours: Crew members:
11. List materials used:
12. If you had an accident/incident while performing this request, did you report it? YES or NO
13. Water Utilities meter inspection: PAS: or FAIL �s
14. How many trips to do task? ( G/
Signature