333 Charleston • WA R
Issued TLnished staploye / � G id ••ap
Name:
-dress: • d
Phone Number: (8M): (yam):
Time for Water locate
Check for: Accuracy we Mder Laid= Leh water mum: bidet ems cdocadoa ctiaq__ Area!
1.8ackflow Insv. 2. $.air 3 .111i21e2222e s.an
Backflow Insp. A.Kairt Liao A.puarpa
7l.Liru Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.0ate C.Service Lino C.Saaplea C.Tap
• D.Uydrants D.Bquipment D.Excavatioa
Re -Cert. Date E.Safety
S. Reason for failure: A. Zlectrolysia B. New construction C. Poor inatallatio
6. List of safety equipment at site if applicable: D. Other
A. Barricades B. Cones C. Tape D. Lights i. Other
Request for Serviceman:
r (5'c I
7.If Motor /Service Leak: Classify- City: Customer: •
T7�
A. Water Loss own*: GPM lire plug flushing _ Total Gallons •
B.Was Water Metered: • Yes ___ No
C. Was Customer Notified: Verbally 2002E210CE11R
• Vehicle/Bquipme d: Used
$.If Mater Change Out: Unit # Miles grs Equip
A.Old Metsr# Reading_
8 . New M - r42.Y Readin - • ,
C.OId Meter Si :e/ : D. • ��
zYPe New Meter Slse /Type � 15 � �._
E.Type of work performed or findings:
2
9.if mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: / Craw members. :
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LL.Liit Materials Used:
12.1f you had an accident/Incident while performing this e esc. aid you report it7 yes or nc
13.s+ater UtiULties meter inspection: pass or fall ^- " J
L1.Hcw rainy trips to do task? _