719 Clayton � WATER
:sewed i - izished -� /A
Employes ' t(' -- 7a' ,1 00e114 map
:lame: Address: ?l7 c4- ito (,i r1cie—
?hone Number: (EM): (WX) •
Time for Water locate
Check for: Accuracy trier_ Meter Leak: (Meet water preaure: Initial meter relocation inocmcion
Mead
I.Backflow Insp. 2. Repair 3.Maintenance `.O ez
Backflow Insp. A.Main Line A.Pumpa A.Line Locate
B.valves B.Water Tower B.Inapection
Bk.low Cert.Date C.Service Line C.Samples C.Tap
Re -Carr. Date
0.3ydrants 0 .3quipment D. Excavation
E. Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
6. List of safety equipment at site if applicable: 0 Other
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request. for Serviceman:
7.1%1 Meter /Serr:ce Leak: Classify - City: Cust
A. Water Loss (E imuat: GPs ____ ?ire plug f lushing =oval Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: verbally DOORICNOCKER
Vehicle /Equipment Used
3.r_ Meter Change Out: Unit if Hiles Firs Equip
;.Old Meter #Tf t 3 4 ( Reading ( 1 q 551
3. New Meter)* ' A a e3 -- Reacting 0 5 1
s �/ 3
C. old Meter sire /'ape: 1 CC '7j b (� /` " 1,1
D. New Hater size /Type YV‘c,-S4 C V /5/
I. Type of work performed or findings: V'\ (4 .- v awl -L -- F •
9.If mainline or deep service repair, describe type of pipe or service line and condition:
i0.Manhours: 1 p
.' ) Crew members: _(
.I.Liat Materials Used:
2.If you had an accident /incident while performing this request. Did you report t? yes or no
.3.Water Utilities meter impaction pass or fail .„/ fec,
4.How many trips to do tasks j
Signature