2001_1108 WATER
Issued: // / n ,., 0/ Finished /l EznPlayee; ally) L Grid /
Naate: \(�J��11'1, L n A 1 1 l Address:
Phone Number (IN) � (WIC):
Check for A::taracy test: Meter Leak: Check water pressure:
Initial mete: r_Ioation;asx:=ons Re -read
1. Hacktlow Iasy, 2. $tax 3. Maintenance 4. Oka
Backflow rasp. A. Main Line A. Pump A. Line Locate
Bkflow Cat Date B. Valves 3. Water Tow:: B. Line Locate
Re -Ce:t Dace C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reason for failure: A. Electrolysis B. New Construcdoa C Poor Tastallatoon D. Other
6. List ante equipment at site if applicable:..
A. &rricades B. Cones C. Tape D. Lights E. Other
Request for Services: �(C\._071
7. If : :: "Se ic: Leak: Cass - City: Customer
A. Water Lou (estim.): GPM Fire plug flushing Total Gallons
E. Was WaterMetetel: Yes No
C. Wu Customer Notified: Verbally Doorlmocker-
Vehicle/Equipment Used
S. If M: ::: Cs: se Out: Unit # Kies Hrs Equipment
A. 0:d Meter; /79;_,,,L72-- � Reading
3. New Meter 4a5`j Reading
C. Old Meter Si iT p D New Meter Size/Type
E. Type of work peforred or findings:
9. If rn'intire or d • s e .r ir, des • type of • ipe or service line and condition
• u �.
10. Mesa- bc_-s: Crew Members. R_,091
II. List Ma :era's Used:
12. If you 4a: a- ac ::dcnc/?- :.:::t while performing this request. Did you repo.: :' Yes or no
13. Water Laces meter icspe :cn: pus or fa::
14. How many zips to do task?
Signature