728 Cardinal WATER
Issued finished ' P Employe ° t'''' � Grid map
Name: Address: 7U 014 ;11 /
?::one Number: (BM): (WX):
Time for Water locate
Check for: Accuracy Lase_ Mctar Lea/c _ Meek water pressure: Initial tomer relocation inrgatioa d
I.Backflow Ipso. 2. Repair 3.Maintenance 4.0ther
eackflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inapection
Bk.low Cert.Date C.Service Line C.Samplea C.Tap
D.Bydrants D.Squipment D.Excavation
Re -Cent. Date E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
b. List of safety equi went at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.__ Hecer /Sersice 'Leak: Classify - City: Customer: -
A. stater Loss (Fstimate t: GPM Fire plug flushing Total Gallons
S.Was Water Metered: Yes No
C. Was Customer Notified: Verbally DOORll09oCEER
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles ars Equip
A. Old Meter # Y 3 0 /? 31 Reading t c d4„
3 . New Meter* oa a (3 LP -11 1 Reading clip
C.Old Meter Size /Type: & � ( D. New Meter Sizs /Type 01 As ICV /v f- X ; i
I. Type of work performed or findings: iM t' fru' cat aly-- 06 0
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ,' -S Crew members: _l
II.List Materials Used:
12.If 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 trips to do task? �,-
Signature