0407 . WATER
DD
.sewed _ Finished `�� Employee DA'J Grid map
:lame: Address: 515 4 6, s' v2 6 C.7
?'lone ;lumber: (SM) : (WX) :
Time for Water locate
Check for: Accuracy ua :_ Meter Leak: CSeek water presaare: Initial mice mlocation iapecaoa
Ri -mad
I.3ackflow Insp. 2. Repair, 3.Maintenance 4.0ther
Sackflow Insp. A.Main Line A.Pumps A.Line Locate
3.Valves S.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.3ydrants D.Equipment D. Excavation
Re -Cert. Date - E.Satety
s. Reason for failure: A. Electrolysis S. New construction C. ?coy installation.
D. Cther
6 . List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Oche:
Request for Serviceman:
Meter /Service Leak: Classify — City: Customer:
;.Water Loss (Fjtimaut: GPM ?ire plug flushing Total Gallons
3. Was Water Metered: Yes No
-.Was Customer Notified: Verbally
Vehicle /Equipment Used
3.I! Meter Change Out: Unit f Hiles Mrs Equip
A.Old Meter# • 7 7 g 7 Reading /OODO 11 �9 ?Qy0
3. New Meter# 73 1 9 9 3 Reading 6 I
MAS�� a-k f2 s 1
Cold Meter Size/Type: P./� S
�IL D. New Meter Size/Type --
(.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: " Crew members: Z
LL.List Materials Used: 10 k2
12.rf you had an accident /incident while performing this request. Did you report it? yes or n°
13.Water Utilities meter inspection: pass or fail
.4.How many trips to do task?
Sicnature ___