710 Clayton WATE
sewed 1 finished 5 -- ' Employee 1f T.:1-4 Grid map
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Name: Address: - 7/ 0 c y�OV, L(/.�
?hone Number: (3M) : (WE): ® .
Time for Water locate
Check for: Accuracy Maar Leek: Cheek enter per te: iaitial awn relecatioa lb - read
I.3ack` low Ipso. 2. Revair 3.Maintenance Ot e
`
eack_low Inap. A.Main Line A. Pumps A.Liae Locate
9.Valves S.Water Tower S.Inspection
Bkflow Cerr.Date C.Service Line C.Samples C.Tap
Re -Cep. Data O.Hydrant D.Equipment D.Excavation • E .Safety
S. Reason for failure: A. Electrolysis S. New construction C. Poor installation.
D. Other
o. List of safety equipnent at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.:f Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Faiacata r: GPM ?ire plug flushing Total Gallons
3_Was Water Metered: Yes __ No
-.Was Customer Notified: Verbally __ DOORMOCXER
Vehicle /Equipment treed
3.If Meter Change Out: 9 Iq Unit # Miles Firs Equip
A.Old Meter# 0 p b g 0 -1 ° ^ / 6 Reading( ` I
3. New Meter# L� (7 L i 7 Reading Q) --
C.Old Meter Size /Type: 6 1 �J �? � 5C -37(1 D. N Meter Size/Type q �l C1/ -. ,5' X�
7
E. Type of work performed or findings: f(✓ALI CL °1 O '.
9.If mainline or deep service repair, describe type of pipe or service line and condition:
IO.Manhours: c l) Crew members: '�1
:1.List Materials Used:
2.tf you had an accident /incident while performing this request. Did y report it? yes or no
.3.uatac Utilities meter inspection pass or fail j
i.How many trips to do task?
-rill- Signature