112 Cherrybark WATER
Issued 9 Finished Employee /., Grid map
Name: 9Y AddrsOF : 1/ a, ei // Jd
?hone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy wt: Meter Leak: CbecY water pressure: Initial meter mlocatioa inspection Re
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1.Backflow Inso. 2. Repair, 3.Haintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Skflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason fcr failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape l` D. Lights E. Other
Request for Serviceman: `116-.(4, *4 ?4 C 17 `3
6
;.If Meter/Service Leak: Classify - City: Customer:
A. Water Loss (Fstimaic : GPM Fire plug flushing Total Gallons
S.Was Water Metered: Yes No
:-.Was Customer Notified: Verbally DOORIQdOCIQ+R
Vehicle /Equipment Used
3. If Meter Ch c Out: (l Unit # Miles Hrs Equip
A. Old Meter# d `1 �O 6 7t1 3 7 Readin Z � LA - / . 9 .. ,
'
3.New Meter # r 3 ;5 - 7 Reading 0
C.Old Meter Size /Type:/ / / D. New Meter Size /Type "/� /'//
E.Type of work performed or findings:
e A- ( /(l PtAof,7
g uz3 �
9.If mainline or deep service repair, describe type of pipe or service line and condition:
lO.Manhours: Crew mea(bers:
11.Liat Materials Used:
12.2f 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? 1
Signature ' ,