1204 WATER
issued Finished v / Employee � / Grid map
Name: Address: er 2F //l c'
?hone Number: (sm): (WX):.
Time for Wats: locate
Check for: Accuracy tae:_, Maar Leak _ Cluck water pressure: Initial moor relocation impaction R►tsad
1.Backflow Inen. 2. WALL 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 ft.= 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:
Meter /Se ^rice Leak: Classify - City: Customer: .
A.Water Loss (Fscimaul: G ?M :ire plug flushing Total Gallons
;.Was Water Metered: Yes No -------
„.Was Customer Notified: Verbally DOORENCKNOCR
Vehicle /Equipmens Used
3.If Meter Change Out:
2 Unit # Hiles Firs Equip J�
A. old Me= ert , ri. /� / ' 1/� Reading / � � 7/”" 5- 27 • Zg/ ` .
3 I
3.New Meter# Z7? 1 r Reading /�t " y
C.Old Meter Sire /2'ype: 7% '�� 7 . ..._D: -New Meter Size /Type lr /// <
- s.Type of work performed or findings: / j/ ;e i
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: 1, /V Crew members:
I1.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? y es or no
13.Water Utilities metes inspection: pass or fail
14.How many tripe to do task?
Signature