651 Allen WATER
Grid map
Issued ° --` Finished Employee �._
Name: �, , �..� - � Addrs s s : v- � � •. �`
?hone Number: (BM): ( )=
Time for Water locate
Check for: Atcuracy tau: Maar Gat Clad water presume: Initial meter relocation iaspectio _ Re-read
1.Backflow Insv. 2. Repair 3.Maintenance `.Other
Backflow Insp. A,Main Line A.Pumps A.Line Locate
B.Valves B.Aater Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re -Cent. Date E.Safety
Reason for failure: A. Electrolysis B. New construction C. Poor installation
�. D. Other
a. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights r ,E. er
z
Request for Serviceman:
7.If Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Fstimale :: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: Verbally DOORRNOCK R
Vehicle /Equipment Used
3.If Meter Change Out: // Unit # Miles Firs �y! v Equuip
A.Old Meter :7V b 3/ S/ Readin 0 `) _� S / 2 q
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3.New Hezer # .��/ � � Reading
4 ' / � .Old Meter' Sie /':'ype: �� �•� ` l Q i U 4'v1� -/D: � New Meter Size /Type
.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Hanhours: \ Crew members:
11.List Materials Used: �}
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12.If you had an accident /incident while performing this r t. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task?
Signature