300_Brooks WA 1.
: asued Finished . 7 c Employee_ e,e Grid map
Name: Address: also
?hone Number: (BM): (WX):
Time for Water locate
Check for: Accuracy :eat:_ Meter Leak Clack weer pceaaure : initial meter relocation inapatioa Reload
1.Backflow insp. 2. Repair 3.Maintenance 4.0ther
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3.Valvea B.Water Tower 3. Inspection
Bk:low Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safaty
E. Reason for 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: -
;.Water Loss (Facth t : GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
...Was Customer Not. ied: Verbally
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles Mrs Equip
A. Old Meter # 'i) r7 9 s L/ - 1 Reading 1,2 -5
3. New Meter# 2 /0 CJ � 7 Reading 'T
C.Old Meter Size /Type: / A � 5 a/ � % Y
y D. New Meter Size /Type )4?a S h'/ 9 '/Y
E.Type of work performed or findings: t Jr h - •
9.If mainline or deep service repair, describe type of pipe or service line and condition:
iO.Manhours: c Crew members:
U .List Materials Used:
12.Zf you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many tripe to do task? , 1
Signature it4V