604 Burning Tree ] WATER
Zssued — _ Finished 1" '1 Employee' /�/Li/ Grid map
Name: Address: 1,.O '7 /J 0611 i`1i
?hone Number: (EH): (WE): \./
Time for Water locate
Check for: Accuracy tact:_ Meter Leak: Meek water pressure: _ Initial meter relocation inspection Knead
1.Backflow insn. 2. Repair 3.Haintenance d.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.Excavatian
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
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. Mater Loss (Emimatal: G ?M ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: verbally
Vehicle /Equipment Used
3.2: Meter Change Out: Unit # Hiles Hrs Equip
A. Old Meters 1? I t 9 , ° 7 � F Reading / 4 7
3. New Meter # oZ 216 3 Y3-5--Reading k,
.OLd Meter Size /Type: Pict Cc S/. O �r S / s �� D. New Meter Size 04-i/ S ic , ) /
:.Type of work performed or findings: 694
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Hanhours: "4A 4 Crew members:
11.List Materials Used:
12.If you had an accident /Lncident while performing this request. Old you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14. How many trips to do task? / ��