0529 WATER
Issued a3r�� Finished Employee - /��� Grid map
Name: f.) J Address: .109 f11 .
Phone Number: (H4): (WR) :
Time for Water locate
Check for: AccutuY stn :_ Meter LeaJc Check water immure: Initial meter talocuioo inspection R. - esad
1.Backflow Irmo. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Watsr Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re-Cert. Date E.Safety
S. Reason for failure: A. Electrolysis S. New construction C. Poor installation.
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman: �' L-%-C .c- /, ‹i/
7.If Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Estimate :: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOORES1OCiOZR
Vehicle /Equipment Used
3.If Meter Change Out: ` U / it # Hiles Mrs Equip
A. Old Meter# .. J l sr / 7 $ 1- Reading c-' / y G( Z Z;->' I
( (
3. New Meter# -- Z /, Z 2 Reading
,7 / ( C.Old Meter Size /_ e: /�� /,� y -D: •New Meter Size /Type / : �
E.Type -f wor performed or findings: / .7—el
/ G � 71' .�i — c � �
9.If mainline or deep service repair, describe type of pipe or service line and condition:
•
1O.Manhours: 3 /sf Crew members: j
11.List Materials Used:
12.If 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 tripe to do task?
Signature