976 Bethel School WATER
Issued Finished Employee �// / Gr map
�/� '7 p �v Ad es s: q /IL, 1.6-7-14E-t_ slyi�L
Name: L . �' ,7 L �� �. �L G�
Phone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak: Check water pressure: Initial meter relocation inspection Re - read _
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 po
Request for Serviceman: YY1ET 7? is' si < ° It `Q Q
7.If Meter /Service Leak: Classify - City: Customer: `--
A.Water Loss (Estimate): GPM Fire plug flushing Total Gallons
B.Was Water Metered: Yes No
C.Was Customer Notified: Verbally Y / DOORIINOCXER
Vehicle /Equipment Used
8.If Meter Change Out: Unit 0 Miles Hrs Equip
A.Old Meter #.; , ---, Reading
-16 0 I
3.New Meter;t2/� /p (/ Reading
X13 /�? / D. New Meter Size/Type / `� %/
C.Old Meter Size /Type: fF. �� l
6 '
E.Type of work performed or findings:
10 ,7f C 43Afy C 0 L f""
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: - --F-o= Crew members: i
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
14.How many trips to do task?
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