601_Briarglen WAT A.
issued — — Finished , L Employee r t' / 14 1/ � 'v Grid map
Name: Address: (0° 1 r /to" fr /e i
?hone Number: (HM): (WX):
Time for Water locate
Check for: Accuracy %sa :_ Meter L.salc Chock water prssaurs _ laitial mater relocation inapectioa Ra -nsd
l.iiackflow Insc. 2. Repair 3.Maintenance 4.Other
Hackflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
3kflow Cerr.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D. Excavation
Re-Cert. Date E.Satety
S. Reason for failure: A. Electrolysis 3. New construction C. Poor installation.
D. Other
o . List of safety equient at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman: •
;.:f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Egia>aret: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.was Customer Notified: Verbally DOORZNOCIER
Vehicle /Equipment Used
3..f Meter Change Out: Unit if Miles Hrs Equip
A.01d Mater* q'3.. ( It ? Reading 0 9 U.
3.New Meter # f i5 Reading 1
3
..Old Mater Size /Type: L�cl< y l D. New Meter Size /Type /')7ct S 4�'- -r / )<.,
(.Type of work performed or findings: I)"1 P_ 1 e r 1 ct r- e
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: c Crew members: ,
11.List Materials Used:
12.If you had an accident /incident while performing this request. DLd yaui'report it? yes or no
L3.Water Utilities meter inspection: pass or fail /.c •
14.How many trips to do taskl