304_Brooks WATER
Issued — _ Finished 3 - a S Employee '^- VV Grid map
Name: Address: 3OLk 'I.'A'+D'LI( S
?hone Number: (BM): (WIC):
Time for Water locate
Check for: Accuracy test :_ Meter Lealc Chcct rater pm-mum meter relocation inspection d
1.3ackflow Inso. 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.Samples C.Tap
D.Hydrants D. Equipment D.Excavation
Re -Cert. Date • E.Safety
3. Reason for failure: A. Electrolysis B. 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:
A. Water Loss (E insua :: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.was Customer Notified: Verbally DOORICEMK2EA
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles Hrs Equip
;.Old Meter #'1 6 1 I l Reading Y 7
3. New Meter# WI 9 S'1 0 Reading OS
.
C.01d Meter Size /Type: 6 1--C-1 'S ' t 0 `1 D <
D. New Meter Size /Type 11/1 OE 3
3. Type of work per formed or findings: Iw" 1 v (-A Cv, t'
!451- 5�® 0 / G/ tr'lc4 s g 64t3 5
I) wle tf L-✓gS O
9.I: mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: Crew members:
II.List Materials Used:
12.If you had an accident /incident while performing this rogues . Old you re it? yes or no
13.Water Utilities meter inspection: pass or fail t< r
14.How many trips to do task? ,