607 Burning Tree WATER
‘J -
:ssuad iiaished ( Employee / ✓ / Q 004 Grid map
Name: Address: 6 0 7 h 1✓ly r i
?hone Number: (3M): (WX):
:ime for Water locate
Check for: Accurst' tea :_ Meter Leak: (Muck Water present: Initial meter relocation inspection ��
1.3ackflow Inst. 2. Reoair 3.plaintenance d.t?ther
Hackflow Insp. A.Main Line A.Pumpe A.Line Locate
B.valves B.Water Tower B.Znapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re - Cert. Date E.Safety
s. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
6. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
;.If Meter /Service Leak: Classify - City: Customer:
;.Mater Loss (Fstimatel: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: verbally DOOEXMOOCEE
vehicle /Equipment Used
3.1! Meter Change Out: Unit # Miles Firs Equip
,.Old Meter# 1r 7 q 5 Q & 2 Reading '
3. New Heter # 2, 6 39 Reading 0 -
C.Old Meter Size /Type: i cfG car 5 l p -3 / , / D. New Meter Size /Type filet tic,' ' - p X 3/X
�!
s - . T y p e of work performed or findings: A V 1 C
9.1.1 mainline or deep service repair, describe type of pipe or service line and condition:
lO.Manhou C rew members:
11.List Materials Used:
12.2f you had an accident /incident while performing this request. Did you repo it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task? i "'4