0409 WATER
:sewed Finished H Employee, I ,9vicf Grid amp
:tame: Address: s L6 CT
?`tone Number: (3X) :
Time for Water locate
Check for: AscuncY Se: Mctsr Lcsk: Cuct water press= Initial cast :slocatiaa ias4►cc ya.
1.aackflow tnso. 2. Retain 3.Maintenance 4.0ther
3ackfiow Insp. A.Main Line A.Pumps A.Liae Locate
3.Valves 3.Water Tower 3.Inspection
3k=low Ce t.Date C.Service Line C.Samples C.Tap
0.3ydrants D.3quipment D.Excavation
Re —Cep. Date E.Safety
I. Reason for failure: A. Electrolysis 8. New construction C. Poor installation.
D. Other
3. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape �// D. Ligh ts E. Other
Request for Serviceman:, (t i9 K i2 /e, x'1 ChK12 f, 490`7
7.:! Meter/Service rice :.eak: Classify — City: Customer:
A. Water Loss (E iaata): GPM ?ire plug flushing Total Gallons
3 as ate: Metered: Yes No
C. was etzstomer Notified: Verbally DOORICNOCEER
Vehicle /Equipment Used
3.:f Meter Change Out: Unit # Miles ars Equip
;.Old Meter* r 7`7 %0 Z Readin / / ,K(` / 3 y `C Z9Z_o cC glv
3. New Meter Z3/ 1 Reading
C.Old Neter Size/Type:/ C.G 1//e i &
X:- � D. New Meter Size /Type 5�/� )#
e-- -
U
I.Tvpe of work performed or findings:
9.If mainline or deep service repair, describe type of pipe ar service line and condition:
10.Manhaurs: ' Z Crew members: \ Q
LL.List Materials Used:
12.rf you had an accident /incident while performing this request. 0.d you report Lt? yes Cr no
:3.water Utilities meter inspection: pass or fail
.4.How many trips to do tas%c?
S icna_ure