612_Briarglen WATER
asued • i iaished , S , Employee r' e / //q hi t' &if Grid map
Name: Adds-ems: (/ r jrler/
?hone Number: (EM): (WK):
Time for Water locate
check for: Aeeurscy sere._ Meter Leak: Cluck water pressure: Initial meter relocation impectio _ d
I.Backflow Insc. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3. Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.3ydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
3. Reason fnr failure: A. Electrolysis 8. New construction C. Poor installation.
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:
..Wafer Loss (Fssintatet: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
Z. was Customer Notified: verbally DOOREMTGC7l$R
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles lire Equip
A. Old Meter* rS 7 i * Z--`T y Reading i2
3. New Meter # NCO ca 5 Reading
C. Old Meter Size /ape : I ccY y 5 - - /4 X 7 14 D . New Meter Size /Type /Via S /(' X- 1
:.Type of work performed or findings: re f C ( G 1? c, h Wit)
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Hanhours: i Crew members: f
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or n°
13.Water Utilities meter inspection pass or fail / many trips to do task? _