201 Hollowtree W ATER
Issued — __ rinisied Employee :3 Grid map
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Name: Address: i VO / /iac.)
?hone Number: (BM) : , (WIC):
Time for Water locate
Check for: Accuracy me:_ Man L.a! _ Cuba yew pressure: Initial man ntoca on ia+ps+o _ 1tte+sd
1.Backflow Inn., 2. MILE 3.Maintenancs 4 .21112X
Back:law Insp. A.1lain Line A.Pumps A -Lief Locate
B.Valves B.Water Tower H.Inspection
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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 B. New construction C. Poor installation.
D. Other
o. List of safety equipment at site if applicable:
A. 3arricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman: A1/17 .c 7 C A
7.Z! Meter/Service Leak: Classify – City: _ Customer: _
Water Loss (Fsamusl: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
:7– Was Customer Notified: Verbally DOO S3MIC=S8
Vehicle/Equipment Used t
3.:: Meter Change Out: Unit # Miles Firs Equip
..Old Meter # ?773 , Rsading/00 C. ! o
`7
'/ (
3 . New Meter# d 2 tai. / ? Reading _
C.Old Meter' Size /Type: otici • •• ••. --D --New Meier Size/Type / //i• - - -
Z.Type of work performed or findings:
r_ /2( AK ,N' oaf
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours: , 1 Crew members; __;
IL.List 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 . •
le.Row any trips to do task?
S igrtatur .,..C, °•