118 Cottonwood r-� WATER
Issued I Finished Employee !"• S_. Grid map ____
Name: s �( 1=C n Li Ii4,S 7_ kv {mac kA\\ Address: \ \ a ( I F sLi Q C A
Phone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy test:_ Meter Leak:___ Cbeck water pressure: Initial meter relocation inspection__ Re -read
1.Backflow Insn. 2. Recair 3.Maintenance 4.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
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman: 0 IA py\ f 9k- 1M r `-1- — S 4 (\, L I 0
7.If Meter /Service Leak: Classify - City: Customer: �_
A.Water Loss (Esimae): GPM Fire plug flushing Total Gallons
B.Was Water Metered: - Yes No
C.Was Customer Notified: Verbally DOORENOCCER
• Vehicle /Equipment Used
8.If Meter Change Out: Unit Unit # Hiles 7s Equip
A.Old Meter# flS 7 O D Reading 7 / ( 2 " U - /C ?7v '
a
B.New Meter #i q e / / ! / Reading ,
C.Old Meter Size /Type: I fYJ y � r� D. New Meter Size /Type
E.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
1 �
10.Hanhours: ( ' Crew members: i
11.List Materials Used:
12.It you had an accident /incident while performing this request. � Did you report it? yes or no
?f 13.Water Utilities meter inspection: pass or fail .1
14.How many trips to do task? Signature