317 Charleston WATER
Issued Finished Employee � 4 � L-- Grid map
Name: 0 OA 1 Sh19/2 AJ Address: 3 ) f) C h Ard k_4-•o,U
Phone Number: (KM): (WK)
Time for Water locate
Check for: Accuracy test_ Meter Leak: Check water pressure: Initial meter relocation inspection Re-read
1.Backflow Insp. 2. Repair 3.Maintenance 4.Qther
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman: r C/ ( fr, /2_ g 79€52 k-c,
7.If Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Estinine): GPM Fire plug flushing Total Gallons
B.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOOM
• Vehicle /Equipment Used
8.If Meter Change Out: �j /� Unit # Hiles Hrs Equip
A.Old Meter# Y 9 W 6 oReading96 3 5 L J ' �J
B .New Meter# . - I 3 i ? /Reading '
C.Old Meter Size /Type: ,C/K
i}(1 _ (2- D. New Meter Size /Type
L-5 2 1 /? /7.! 4 /
E. Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: / /3.- - ) Crew members:
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task?
Signatur .