2001_1116 WATER
issued: I /444 -C) Finisher: Employee: i nr) Grid map:
Nast _ Address _ 2�
Phone Number. (TN) (WK)
Check for. Accuracy test Meter Leak: Check water pressure:
Initial meter relocation :ripe :dotss Re -read
1. B ackflow lase, 2. Repo 3. Maintenance 4. Qikt
Backflow Gasp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cent. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equ:-pmeat D Excavation
E. Safety
S. Reuoa for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety equipment at site if applicable:
k Barricades B. Cones C. Tape D. Lights E. Other
Request for Services: ✓rig - rQ Q nir__P1.3'ir9 4 6 ICS CT `a to t .&1. lay •
7. If Me :: Senic: Leak: Cus - City: Customer
A. Water Loss (era): GPM Fire plug flushing Total Gallons
B. Wu Water Masted: Yes No
C. Wu Customer Notified_ Verbally Doorknocker -
Vehicle/Equipment Used
8. If Meier C;ar.ge Out: Unit ° .Miles Hrs Equipment
A. ad Meter 4 ,) y03 /) 2 Reading Co 3
B. New Meter s ;24 ''2.$ 97 Reading n
C. Old Meter SiwT;+pe: 6 4/76"1 - 72 -1 2 D New Meter Size/Type % ' C .
E. Type of work pefor=ed or findings:
C/7i1/6c.' ci .' T / IT�z
7) /947 /1/9 - 4 2 /
9. If mainline or deep service - - describe type of pipe or service line and condition
10. Man- hours: Crew Members.
11. List Materials Used:
12. If you had a- is :idcttr? - :.d :rt while performing this request. Did you report le Yes or no
13. water 1.o1loe8 meter iaspe; den: pus or fail
14. How aunt' zips to do task?
Signature