209_Bricknell WATER 6) I�
Issued //-4I/1_, Finished 1/ 10 Employee _ 4`�` Grid map
Name:
IVv ) � Address: 2 I?PJCKIJ&
?hone 0 6l Number: (HM): (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspection Re -read
1.Backflow Insp. 2. Repair 3.Maintenance 4.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.Eamples C.Ex.Tap
D.Hydrants qu P
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C . Other installation . Poor
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights /� E. Other
^^
Request for Serviceman: ! 1� v 6-`� �I/ l S c� ei
7.If Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Estimate): GPM Fire plug flushing Total Gallons
B.Was Water Metered: Yes No
C.Nas Customer Notified: Verbally DOORKNOCKER
Vehicle /Equipment Used
8.If Meter Change Out: Unit i Miles Hrs Equip
A.Old Meter# 3 /9905 Reading 2:t
y � I
B. New Meter# L & �J vJ
C.Old Meter Size/Type: "A X '7/`1 D. New Meter Size /Type ) 7 " r
E.Type of work performed or findings: / P) C 7 1
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: , 5 Crew members: G"'•4
11.List Materials Used:
12.If you had an accident /incident while performing is request. Did you report it? yes or no
13.Water Utilities meter inepectioq: pave or a
14.How many tripe to do task? /
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