641 Bella Vista WATER
Issued SI finished em p l oyee / Grid map
Name: bl d / . 4 G& . Address: 6,e // stele" .4._ ai -c.aQ
Phone Number: (MI): (WX):
Time for Water locate
Check for: Acc armor ea __ Meter Lea Cfarcit va:sr pnssuo _ Initial aawr r.{ocadoa iospectioq_ Ra•etad
1.8ackf low Insp. 2. gemair 3. 4aint, pang 4.Othe=
Backflow Insp. A.Xain Line A.Pumps A.Liaa Locate
B.Valves B.Mater Tower B.Inspection
Bkflow Cert.Date C.Service Lino C.Samplea C.Tap
• D.Eydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
S. 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: L_ _ ""_4).9 ti - ____ _ - -
J
7.If Meter /Service Leak: Classify - City: Customer: •
A.Water Loss ma-04: GPM Eire plug flushing _____ Total Gallons
B.Was Water Metered: • Yes __ No
C. Was Customer Notified: Verbally DOONNINOCZER ___
• Vohicle/Egnipmsnt Used
S.If Meter Change Out: Unit # Hiles Hrs Equip
A.Old Hater# 2 35 7 Reading99 1 1
S .New Meter# oZ I 0 1 5 Reading 0 6
C.Old Mater Size/Type: 0 x3/'-I Pi itAV D. New Mater Size /Type %R X/q (7qs /c
E.Type of work performed or findings: ..e1 C- 04 .
9.If mainline or deep service repair, describes type of pipe or service line and condition:
10.Kanhours: Ac Crew members: 2 '
11.List Materials Used:
11.If you had an accident /incident while performing this request. 01d ou report it? yes or no
13.Water Utilities meter inspection: pass or fall /� 2 - )
14.Hcw many trips to do task? _