1208 WATER
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Issued Finished / /- 2 7/ Employem_ / % /�G�" p ��
Name:
Address: /3 /iG,G'� ,5l
?hone Number: (EM): (WX):
Time for Water locate
Check for: Aceunry vac_ Mao Lsalc Cock water pressure: Initial man relocation impaction _ Rs
1.Backflow Insn. 2. Repair 3.Haintenance 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 fai lure: A. Electrolysis B. New construction C. Poor installation.
r ' D. Other
o. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Estimate:: GPM Fire plug flushing Total Gallons
S.Was Water Metered: Yes No
_.Was Customer Notified: Verbally DOOR»OCQ:R
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles Mrs Equip
A. Old Meter # .fl 2 Z Z / / Reading 15 3(J G: g �‘� �
3.New Heter0/ /c f Z Reading7 7 I
C.Old Meter Sire /'Type: / // ((5/4 -----D: Mew Meter Size /Type / 1 / /I/s i A
E.Type of work performed or findings: 5A gt t' .9I)'/'
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: 7 l// Crew members:
I1.List Materials Used:
12.2f you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities ester inspection: pass or fail
14.How many tripe to do task?
Signature,