1209 WATER
Issued ` Finished 1,2 , Employee / / 4-1' Grid map
Name: Address:
?hone Number: (HM) : (WA) :
Time for Water locate
Check for: Accuracy we _ Man twaJc amok ureter pesawue _ Iaiaat meter relocation lamination Rrresd
1.Backflow Insv. 2. Repair- 3.faintenanee 4.Other
Backflow Insp. A.Main Line A -Pumps A -Line Locate
B.Valves B.Water Tower B.tnapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
Reason far failure: A. Electrolysis B. New construction C. Poor installation
5. construction D. Other
O. List of safety equipment at site it 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 (Fss000: •GPM . ?ire plug flushing Total Gallons __
3.Was Water Metered: Yes No __
:.Was Customer Not: -tied: Verbally DoOWIOcaEA
vehicie /Equipment Used
'S>41,3()(18617 unit # Hiles Mrs Equip 3.I_ Meter Change Out: Unit
�j
A.014 Meter. Reading / 7W2 / I % t c J II •' ; C/J, 0 3 9'O
3. New Meter# la 3 4 Reading 100000 i f
^.Old Meter Sice /'.Type : -' i,, Vida fle( ill ... -D: ""New Meter Size /Type • / "'' ,1?a
:.Type o f work performed or findings: Siv e! I , of m r frr
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours: , 1 , Crew members:
* II.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.1later Utilities aster inspection: pass or fail
14.Bow many tripe to do tank?
Signature,