2001_1203 WATER
issued: (/ ' U /Finished /a � Easp1oycer
Grid map:
Name: $ A. - a . S i I " , Address: 0 . p p k kZ
Phone Number 00.0 (WK)
1?OArs - Y9a- f'Sy /9S
Check for Actuary rest Meter Leak: Check water pressure:
Initial mete: reloadon insx.,.ons , Re -read
1. Hackr1ow lase, 2. &air 3. Maintenance 4. Q
Backflow rasp. A. Main Line A. Pump A. Line Locate
BkRow Cert. Due B. Valves B. Water Tower B. Line Locate
Re -Cert. Date C. Service Line G Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reason for failure: A. EIectrolysis 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 Serv'ces: C 1 1.L4 1 cur) T yy, 6
r �
7. If Lieter'Se:vtc: Leak: Cess_y : City: Cus:orae:
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Wu Customer Notified: Verbally Doorlmocker -
Vehicle/Equipment Used
8. If Me:e: C.:a: g: Out: Unit # Miles Hrs Equipment
A. Oid Meer 4 Reading
B. `ex Meter 4 Z Reading
C. Old Meter Size/ ype New Meter Size/Type
E. Type of work peon-zed or findings:
9. If mainline 1 deep servi -: repair, d . crtbe type • f pi • or service line and condition
•. I . .,
10. }tan - hours: Crew Members. 4 -11 4-
11. List Materials esed:
12. If you hat! se rce :dc wT : :. :cc while performing this request. Did you repor ic? Yes or no
13. Water (:alcces -teen icspe: :ern: pus or fa:1 •
14. How truny tips to do task?
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