605_Briarglen WATER
Issued - - Finished : 3 / 41.4441.441A. -5 Employee .t, � Grid map
Name: , Address: 6 0 5 ID Y l ca v it. li
?hone Number: (HM): (WK): .
Time for Water locate
heck for: Accuracy teat: Meter Leak: awck water pressure: Initial meter relocation inapccno Re-read
1.3ackflow Ingo. 2. Revair 3.Haintenance d.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re-Cert. Date • E.Safety
5. Reason for failure: A. Electrolysis 8. New construction C. Poor inatallatior.
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.:f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Fstimue r: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: Verbally DOOR.IOCEER
Vehicle /Equipment Used
3.If Meter Change Ou Unit # Miles Firs Equip
A.Old Meter* 5 3 v g 3 g O Reading2 9 S 3)
3. New Meters /1 Reading C) S I
0
C.Old Meter Sise /Type: injitt/ �) /` 4 D. New Meter Size/Type itq /
o.Twe of work performed or findings: tIvidt-vt Clikvit 69 "(
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ,; Crew members: 1
II.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: pass or fail
K /
14.How many trips to do task? f/ v
Signature /:5V \"