615_Briarglen WATER
: asued _ i inishsd -� _ l Employee 7 C ��� at 1 Grid map
Name: Address: 4;25 /,2 vi 1 ca ✓y /e--4-7
?!lone Number: (EH): (WX):
,l
Time for Water locate
Check for: Accuracy sat:_ Meter Leak:_ Clock avatar pressure: Initial meter relocation inspection d
I.3ackf low Inso. 2. Repair 3.$aintenance d.Other
Sackflow Insp. A.Main Line A.Pumps A.Line Locate
3.Valves B.Water Tower B.Inspection
Ekflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cent. Date E.Safety
S. Reason for failure: A. Electrolysis E. New construction C. Poor installation.
D. Other
ii . List of safety equipent at site if anolicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
•
Request for Serviceman:
Meter /Service Leak: Classify - City: Customer:
;.dater Loss (Fstima&.i: G ?M Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.was customer Notified: verbally DOO1tE11TOCEEt
Vehicle /Equipment Used
a._f Meter Change Out:
1 I Unit # Miles Hrs Equip
A. Old Meter# 43 v `1 `1 Reading g 3 9 S
3. New Meter # 2 / 0 5? 5 Reading C
C.Old Meter Si =a /Type: fZ 1 ee f X , D . New Meter Size /Type 7i S 7 cr
E.Type of work performed or findings: M C: e -/ C1 , 77 c
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . Manhours : "� 5 Crew members: [
I1.List Materials Used:
12.tf you had an accident /L::cident while performing this request. Did you report it? yes or na
1.3.Water Utilities meter inspection: pass or fail
14.How many trips to do task? t / '�'� / i 1-- )