329 Charleston rt).
Issued finished WATER
lmpLo - 1 Grid map
Naas*: Nae: - - ens: • MIW I II Al 7 ,A/
Phone Number: (ffi't) : ( yam )
Time for water locate
r
Cheek for: Acetone► r r Messetwalc Checkvimmemsawn faioal mine teloe,8,a;r4'etio4_
1.Backflow Viso. 2. Recair 3.Maintenanee 4.2th__
r Beckflow Insp. A.Kairt> Line A. s
� A.Liaa Least.
!.Valves 8.Mater Tower B.Insp.ction
Bkflaw Cert.Date C.Servic. Line C.Sasples C.Tap
D.Eydra*ts D.squipeent D.Excavation
Re -Cart. Date E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installatio
D. Other
6. List of safety equipment at site if applicable:
A. Barricades D. Maas C. Tap. D. Lights E. Other
Request for Serviceman: .
M/ 7..c l'9/'V'-- 6 C,±
7.If Meter /Service Leak: Classify: - City: Customer: _T_
A.Water Loss (Fsi■w): GPM Firs plug flushing _ Toth Gallons
B.Was Water Metered: • Yes No
C.Was Customer Notified: Verbally _ 17043113303CEIR __
• Vahicle/Equipmeat Qsed
i.If Mater «+ • Out: Quit # Miles 8rs !quip (�' 11
A.OId Me- r# Reading ^ `� � V
1
8.New Meter: 2 Readin-
3. --Zi---.--
C.OId Meter Size /Type: D. New Mater 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:
10- Kanhours: \ V Crew members:
11.GLst Materials Used: `
12.Ie you had an accident /Lnctdent while,perforteing this requ st you report it? yes dr nc
13.uater UtLlLties meter inspection: ye `: or faLt Tie Y'' �� .
1
4.Hcv man t s to do task? :
y P _ ._,