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1208 WATER Issued Finished < Z Employee /1141;; , Grid map ..__. Name: Address: G / /r%c'•4, , ?hone Number: (HM): (WK):. Time for Water locate check for: . tcwac7 wt :_ Maer Leak Cbeck water pma a _ Iairial maer talocuWa impccbO _ Rsttad 1.Backflow Inez. 2. Repair 3.Maintenance 4.Other Back_low Insp. A.Main Line A.Pumps A.Line Locate B.Valves B.Water Tower B.Inspectioa Bkflow Cert.Date C.Service Line C.Samples C.Tap D.Bydrants D.Equipment D.Excavation Re-Cert. Date E. Safety Reason for failure: A. Electrolysis B. New construction C. Poor installation. S. D. Other n. List of safety equipment at site if applicable: A. Barricades 3. Cones C. Tape D. Lights E. Other • Request for Serviceman: ;._f Meter /Service Leak: Classify - City: Customer: :,.Water Loss (Eaimata :: GPM ?ire plug flushing Total Gallons S.Was Water Metered: Yes No C.Was Customer Notified: Verbally DOOR 1OCBSA Vehicle /Equipment Used 3.:f Meter Change Out :: f �/ Unit # Miles Ers Equip A.Old Meter # " / 7 7 f 7 %; Reading? /7J ©47 //---/, P 7 Z ` ,, k' 3. New Meter# Z ' 3/}V Reading V 8" �fl . C.Old Meter Size /Type: / .e,- � fF f •• : Meter Size /Type ` I .Type of work performed or findings: S `V/ /,rte. 9.If mainline or deep service repair, describe type of pipe or service line and condition: 4O.Manhours: / Crew members: / II.List Materials Used: 12.If you had an accident /incident while performing this request. Did you report it? re or no 13.Water Utilities meter inspection: pass or fail 14.How any trips to do task? Signature,