205 Carriage 4,i
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WATER
Issued Finished Employee SD E.- Grid map
Name: .Z - L O Am. - y Address: e7 C1'2 ✓L/ / /ce_ C^/-- Phone Number: (HM): (WK): //
Time for Water locate
Check for: Accuracy teat: Meter Leak: Check water pressure: Initial roster relocation inspection Ito
1.Backflow Insp. 2. Repair 3.Maintenance 4.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.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman: C . h0 / / l I j ��/r'` , R � C 9 O
•
7.If Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Saimaa): GPM Fire plug flushing Total Gallons
B.Was Water Metered: - Yes No
C.Was Customer Notified: Verbally DOORS: NO=1R
V■hicle /Equipment Used
8.If Meter Change Out: 7 Unit # Miles Hrs Equip
A. Old HeterI O 1 Z� Reading/ 7 ' L( - / 6 7` / O 7 -?O, 3 �6
3. New Meter# �/ ' T ? / Reading 0 I
C.Old Meter Size /Type: S/ (5:40/7.:5_,-. D. New Meter Size/Type e %:e
E.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ) 11-- Crew members:
11.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 C J
14.How many trips to do task?
Signatu • e