737 Cardinal WATER
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:asusd _ _ ?i:tished . 1 Employee, �`�✓ 1 •` °�� Grid map
Name: Address: = 7 vJ6r0.k
?hone Number: (EM): (WK):
Time for Water locate
Check for: Accuracy ti : Maur Loak _ C'„�cc water pressure:_ Initial meter relocation inspection a
1.3ackflaw Inst. 2. Retair 3.}laintenance 4.Other
Backfiow Insp. A.Main Line A.Pumpe A.Line Locate
3.valves 3.Water Tower B. Inspection
Bkflow Cerr.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
o. 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. plater Loss (Fstimua;: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOOR3NOCESR
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles ars Equip
A. Old Meter # Z9 13367 Reading � 1 4 f) 1 7
3 . New Meter # L L Reading 07
C.Old Hater Size/Type: P(C (S I 0g► / D. New Type /x'145
t .�
3.Type of work performed or findings: C..4tV G l Meter Size/ Type
j& vim -
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: %AS Crew members: ,
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did you r rt it? yes or no
13.Water Utilities meter inspection: pass or fail --- --
14.How many trips to do task? ( / ` v