625_Briarglen WATER // J L /
:issued Finished �Z 5 Employee L Ib1C f M .e c?./ 7 Grid map
:tame: Address: (ZS T I 'f 11 /-e
?hone Number: (aM): (WR):
Time for Water locate
Check for: Accuracy tut :_ Meter Lsal c deck water pressure: Initial meter relocation inspecting Rad
I.3ackflow Lnsn. 2. Repair 3.Haintenance `.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3.Valves B.Water Tower B. Inspection
Skflow Cert.Date C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
o. List of safety equipsent at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7._f Meter /Serrioe Leak: Classify - City: Customer:
:..Water Loss (Egjn c : G ?M Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: Verbally DaMMENOCIER
Vehicle/Equipment Used
3.1f Meter Change Out: Unit # Miles Mrs Equip
A. Old Meter* 1.1 '2_5 ( T1 Reading d 5 --) 7
3. New Meter# ? I O «5 Reading t-/
C.Old Meter Size /Type: 6 ri � 'eV 7 �� 7 � 3 / t/ D. New Meter Size /Type / 1 , , J t� 57f 5�
T
I. Type of work performed or findings: `Gl C '1 ri 1,7 C t /`
•
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: " S Crew members: ,
II.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? y es ar n°
13.water Utilities meter inspection: pass or fail
I4.How many trips to do task? , 1
Signature 1