427_Brooks WATER
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asued a Finished Employee �' 14 /1`I �� 1 ' 14 6 Grid map
:tame: Address: `� 7 t'/L0 1<)
?hone Number: (EM): (WX): •
Time for Water locate
Check for: Accuracy wt:_ Mear Leak: vatar pceaues: loiciai meter :elacaaos iarpec d
1.3ackflow inst. 2. Repair 3.Maintenance d.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
9.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Eydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
S. Reason ft= failure: A. Electrolysis S. New construction C. Poor inatallatior.
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman:
7..f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Eg:imatai: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: verbally DOORMICOCK
Vehicle /Equipment Used
3.:f Meter Change Out: Unit # Miles Srs quip
A.Old Meter# (- w S � 2 7 Reading' ' ®s
3 . New Meter # ,..L10 ) Reading 7
C. old Meter Size/Type :/ R � /g D. New Meter Size /Type /* !N % JSy,
I.Tyne of work performed or findings: fl f el� C� I P 0tJ/
•
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ": Crew members:
LI.Liat Materials Used:
12.tt you had an accident /incident while performing this request. Did you report it? yes or n°
13.Water Utilities meter inspection: pass or fail
li.How many trips to do task?
Signature ` '/Irk