924 S Belt Line WATE
:sewed � • Finished Employee 2,-- rid map
am y- /
Name: t_ a Address: I `i le
?hone Number: (EM): / (�):
Time for Water locate i Y {y cri t T ./
Check for: Accuracy _ Meter Leak: Oak water pressure: Initial meter relocation inspection Re-read
I.Backflow Inso. 2. Repair 3.Maintenance d.pther
Backfiow 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.3ydrants D.Equipment D.Excavation
Re -Cert. Date • E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
S. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.If Meter /Service Leak: Classify - City: Customer: J
A. Water Loss (Estimue l: GPM Fire plug f lushing Total Gallons
3.Was Water Metered: Yes No
...Was Customer Notified: Verbally DOORKNOCEFR
Vehicle /Equipment Used
3.If Meter Change Out: -- Unit # Hiles Firs G Equip
:,.Old Meter
Reading (j_2_21__ / 2 T Q
/ -7
3. New Meter# /9 [ Y ® Reading ( I
/ %/
C.Old Meter Size e: / ;�,`- n G2
Size/Type: D . N ew M eter Size /Type ' "I�
T.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: "` C rew members:
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did yo report it? yes or no
13.Water Utilities meter inspections pass or fail n '1 \
14.How many trips to do task? r � � �l
Signature V`