1204 WATER �n
Issued Finished it to ee L r1 Grid map
Name: Address: r X .-/-7 1 71671
?hone Number: (BI1) : (W1C) :
Time for Water locate
Check for: Accuracy teat:_ Meter Lala Cbeck eater pressure: Initial mater relocation inspection �� Raesael
1.Sackflow Inso. 2. Henair 3.Maintenance l.Otheli
Hackflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bk_low Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
I. Reason fcr 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:
7.:f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Fstiants:: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: Verbally DOORS CKNO R
Vehicle /Equipment Used
3.If Meter Change Out: Meter:* v Z /j Unit # Miles Firs Equip y
A.Old Meter 7 r '7 //� Reading pf .l v: (�% r -/D 2 -/za�`.
3. New Meter# 0 7 , 3/. 7 ' 3/ Reading (//
If/ 5 70 . - /7 ,7,/7 57
.Old Meter Site/Type: / - -43: New Meter Size e
I.Tyoe of work performed or findings: 5` �# iJ
AX72X 1X / 62: r
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: Zr, f Crew members:
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 tripe to do task?
Signature