823 Bethel School i�
:issued Finished Grid map
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ess:
?hone Number: (BM) : (WK)
Time for Water locate
Check for: Accuracy test :_ Meter Leak: CSeck water pressure : Initial Meer relocation inspection Re-read
1.3ackflow Inst. 2. Repair 3.Maintenance d.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
9.Valves B.Water Tower B.Inspection
Ekflow Cert.Date C.Service Line C.Samples C.Tap
D•Bydrants D.Equipment D.Excavation
Re-Cert. Date • E.Safety
S. Reason f r failure: A. Electrolysis 8. New construction C. Poor installation.
D. Other
3. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.__ Meter /Service Leak: Classify - City: Customer:
A.Wazer Loss (Estimate): GPM ?ire plug flushing Total Gallons
S_Was Water Metered: Yes No
,,.Was Customer Notified: Verbally DOORKNOCX3R
Vehicle /Equipment Used
3. I_ Meter Chang c e Ouut: y f� 7�iC Unit # Miles Hrs Equip
A. Old Meter* R ; 5 / . Reading/ $ �7 U`-`. S 1 7 0 2 Q (3
3. New Meter 2213 � 2 Reading
fk -
C.Old Meter Size /Type: ar/ 1Z D. New Meter Size /Type `-% Pl / 7
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: , Crew members:
I1.List Materials Used:
12.If you had an accident/incident while performing this request. Did you report it? yes or no
'
13•Water Utilities p� pass or tail
ter inspection:
14.How many trips to do task? ,
s. Signature