Untitled (6) -� 1 WATER
Issued 67-4ei ' mm --�I / Finished: � Employee: (ree n i/ Grid asap:
Name: v >v L -s T 4 4 Address: / /5 >v &= sr P :5
Phone Number: (HM) OW):
Check for zcuruy :est: Meter Leak: Check water pressure:
initial =ete reiocadoa iasFe^_zoas Re -
1. Haektlow lam 2 -.RePait 3. Maintenance 4. Q
Back low [am. A. Main Line A. Pump A. Lioe Locate
Bkrlow Cert. Dace B. Valves B. Water Tower B. Line Locate
Re -Ce = Dace C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
5. Reason for failure: A. Electrolysis B. New Consuucdon C Poor Installation D. Other
6. List of safety equipment *site itapplicablm
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: L ow P-s
7. If Mere Service Leak: Classify: • City: Customer
A. Waxer Lou (z ate): GPM e s Fire plu flushing / Total Gallons >
8. Was Water Metereck Yes No
C. Was Cuscocer Notified: Verbally Doodmocker -
VehicietEquipmeeat Used
3. if `•t:::r Osage C'.:: tit 4 Miles Hrs Equipment
A. Meer = 4` O6 o Y Reading q L
3. New Meter ? j. '7 / 3 8 4 d Reading f®
C. Old Meter Size type: /°>i a 2- a D New Meter Siz.:Type /14J
E. Type of work performed or findings: it e/=/47
9. if ma'._'.;: a or deep rent: repair, describe type of pipe or service line and condition
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l s : w ^:!e ; e :'cr-ning this .:quest. Dtd y.c .:c: .c Y:s .. :c
13. Ws::: L nlicies mere: rs;.ection: or fail
14. I{o-w .:1:y trips to A ask'
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