222 Carolina WATER r
: esued ?izis:ted t-/- 2 7 Employee / ✓ K � G r i d map
Name: Address: ® ®® (- 4? �- r g if') if Oa
- ?hone Number: (8M): (WX):
Time for Water locate,
Check for: Aeeunc? tsM_ Maar Laic Cock lister pm -um: Initial maer teloation iaspectios Rid
1.3ackflow :nsn. 2. Repair, 3.Maintenance a.Other
3ackflow Insp. A.Main Line A.Pumps A.Line Locate
9.valves 9.Water Tower 9.Inspection
8kfllow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants 0-Equipment D.Excavation
Re -Cert. Data E.Safety
S. Reason far failure: A. Electrolysis 8. New construction C. Poor installation•.
D. Other
o. List of safety equipsent at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
.If Meter/Service Leak: Classify - City: Customer:
A. Mater Loss (Escimusi: G ?M Piro plug flushing Total Gallons
3.Was Water Metered: res No
D. Was Customer Not lied: Verbally DOORMXNUER
vehicle /Egaipment Used
3.If Meter Change Out: Unit # Miles Ere Equip
1.O1d Meter# I L-II L i4 c) -I ) Readin 1
I
3. New Meter* a at /_`�S) Reading (t;
�/� �� /l D. New Meter Size /Type I _14, /3 A4
C.Old Meter Size /Type C c -t
f
E. Type of work performed or findings: Mk 1-t / C o v 4 Col '
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . Manhours : , ". tx , Crew members:
11.Lis: Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or n°
13.watec Utilities meter inspectio r pass or fai1
,,/ 1t
14.How many trips to do task? / J v
s tcnature T