Untitled (11) • WATER
Issued Finished Employe if Grid map
Name: Address: /" � L �� e/-772'
Phone Number: (BM): (WE) :
Time for Water Locate
Check for : Amine? test___ •we Lai Cbscic - seer pewees: Initial mow Aioeadea arp.ctio� yv,esd
1.8ackflow Viso. 2. g*4 34aintsnancs 4.Oth2t
Hackflow Insp., A.Main Line A.Pusps A.Lins Local
3.Oalvee H.Nater Tower B.Znspectio:
ektlow Cert.Date C.Servics Line C.Saaples C.Tap
• D.Bydrants D.lquipment D.Excavatior
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor inatallati
D. Other
6. List of safety equipment at sits if applicable:
A. Barricades D. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.If Water /Service Leak: Classify- City: Customs:: •
A. Water Loss (F,e:ms): GPM Fire plug flushing Total Gallons
H.Was Water Watered: • Yes _ No
C.Was Customer Notified: Verbally __ DOORKNOCICER
• Oshicle/Equipmsat IIsed
CI! Mater Change Cu 1 Unit # Miles Firs Equip
A.OLd Hater# Y f / / / ' / Reedit: 2 /17 7 Z - Z Y1 0 ZFG
3. New Meter# Z 3 Z 27 Reading W/ (•� r
C.Old Meter Size /Type:, 4 ll/1�/ /T D. New Water 3iza /Type / 5". 5 ���
E.Type of work performed or findings:
9.re mainline or deep service repair, describe type of pipe or service Line and condition:
10.Manhours: /Z Crew members: /4
LL.G.it Materials Used:
L1.I! you had an accident /LneLdent while performing this regue:at. 01d you report Ltl yes er