523 Bethel School WATER
issued Finished Employee C�_,._ // ` Grid map �
!tame: Ad ess: k6 c: /✓ Y 25-7
?!lone Number: (8m) : (WR) :
Time for Water locate
Check for: Aecurscy tss:_ Mast Lusk: Chcck water presses: Ionia meter relocation inRecrio _ Re
1.Backfflaw Insn. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3. valves B.Water Tower B. Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Eydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
S. Reason fcr failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
k. 4 f �� eAiy 0v\
7.:f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Eaimusi: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
_.was Customer Notified: Verbally DOOBENOCIODI
Vehicle /Equipment Used
3.Zf Meter Change Out: Unit # Hiles firs Equip
A.Old Meter# � / Reading /u / O / -S , 9/76_2 ? 0
1
3.Nsw Meter #.
Reading v
C. Old Meter Size /Type: �� AV
( /- G � D. New Meter Size /Type s 2'j
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: "71-..- Crew members: /
L1.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or n°
11.Water ?Utilities meter inspection: pass or fail
L4.How many trips to do task? -
S ignore