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1204 WA1 t4,, Issued ?finished / 127 - i Employee / /// 9 Grid ma � _ Name: Address: Z� / 3 /'-, ?hone Number: (11M): (WIC): • Time for water locate Check for: Accuracy tart:_ Maar Leak Cluck water pressure: Initial meter relocation inspection R..rcad 1.Backflow Insv. 2. Repair 3.Maintenance t.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 Reason for failure: A. Electrolysis B. New construction C. Poor installation. 5. construction D. Other 6. List of safety equipment at site if applicable: A. Barricades 3. Cones C. Tape D. Lights E. Other Request for Serviceman: ;.If Meter /Service Leak: Classify - City: - Customer: :..Water Loss (Esimara :: GPM ?ire plug flushing Total Gallons S.Was Water Metered: Yes No _.was Customer Notified: Verbally DOORENOCICER { Vehicle /Equipment Used 3.If Meter Change Out: J Unit # Miles Mrs -- Equip /� :,.Old Meter# Reading / ffi 4 (/, 0,0,�. 3. New Meters ° W)4 - Reading ‘WAY D�©� 7 ,/4.t (-C -Y1� ✓� --42:-New New Meter Size a �� C.Old Meter Size /'ape /TYP 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: , I Crew members: i' 11.Liat 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? Signature. ,