604 Christi WATER
Issued Finished �•
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E mp l oyee � ✓ ' Grid map
Name: Address: J
f)�( j _ S" t
?hone Number: (BM): (WX):
lime for Water locate
Check for: Accuracy tea:__ Metrr Leak Check water pressure: Initial meter relocation inspectiosa
—.� Rs -clad
1.3ackflow Insp. 2. Repair, 3.Maintenance 4 .2t e
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3.valves B.Water Tower B.Inspection
3kflow Cer C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
S. Reason fcr failure: A. Electrolysis B. New construction C. Poor installation.
List of safety equipment at site if applicable: D. Other
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.:f Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Eaimusl: GPM Pire plug `lushing Total Gallons
3. Was Water Metered: Yes _______ No
-.Was Customer Notified: verbally ____ DOORKNOCCEB
Vehicle/Equipment Used
3.If Meter Change Out: q p nit # Miles Ers Equip
A.Old Meter# 6 7 l 1s (f Reading 11 0 7
3
3. New Meter# Reading 0-5
C.Old Meter Size /Type: /6 C4 2# Meter Size /Type
x D. New -4 A '
/1n // �! J
E.Type of work performed or findings: ' dte e- ,4 . OK f
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: r;(3 Crew members: 1
.L.List Materials Used:
2.If you had an accident /incident while performing this request. Old you report it? yes or no
.3.water Utilities meter inspection: pass or fail
1.How many tripe to do task? /
Signature,