528_Briarglen WATER
issued — . , Finished 2' Employee k e f 46_14/ S Grid map
Name: Address: ,7 1Jq✓' lee,
?hone Number: (EM): (WR : \!
Time for Water locate
Check for: Accuracy sot_ Meter Laski_ Check water pressure: Iaicial meter relocation inepee d
1.3ackf1ow trim,. 2. Revair, 3.Maintenance d.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3.valves B.Water Tower B.Inspection
Bk_low Cert.Date C.Service Line C.Samples C.Tap
0.Eydrants D. Equipment D. Excavation
Re -Cert. Date E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
List of safety equipnent at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman:
7. If Meter/Service Leak: Classify - City: Customer:
A. Water Loss (Fstimat&i: G ?M Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: verbally DOCEEMMICOMR
Vehicle /Equipment Used
3.I! Meter Change Out: Unit # Hiles Hrs Equip
A. Old Meter# 715 Q 3 / o Reading]
3. New Meter# g / 0 q5 4 Reading 67 s/
C.Old Meter Size /Type: g' /� p , e % �t S t OVA D. New Meter Size /Type S/ r X /i °IS t'v
Z. Type of work performed or findings: i/y \t✓ t✓ C--1- vet ' 4
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ",5 , Crew members: ,
II.List Materials Used:
12.1f you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection pass or fail Iffitti;t46K)
14.How many trips to do task? t �esZ