1204 WATER
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Issued — . Finished Employe. 4/7/1 Grid map
• Name: Address: //✓
?hone Number: (EM): (WK):
Time for Water locate
Check for: Accuncp toss:_ Maar Leak _ Cheek water premium: Initial mater relocation imgcctios R - read
I.Backflow Inez. 2- WALE 3.Maintenance l.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
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
o. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.1%! Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Etsintata :: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Noti Verbally DOOREZITOCEER
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles Hrs !quip
�% 75 - -- Y7 3 e.///,i7 /i /% Of 277f
.Old Heterr Reading Lf /
1
3. New Meter # � �a� Z "� 2.. Readi.nq �O� •
C.Old Meter Site /Type: - .. / -•--D: New Meter Size /Type } -
E.Tyoe of work performed or findings: /�7� /C� G��� 4„.0'.
4e--/ ` ,/ /mar / e ;t
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: , ✓'/'/ Crew members: f
11.List Materials Used:
12.1f you had an accident /incident while performing this request. Did you report it? rig or no
13.Water Utilities meter inspection: pass or fail
14.How many tripe to do task?
Signature,