1207 WATER
Issued /. _ i inch /, / J Z' 7 Employee Grid map -
Name : l Ce .e4 : �E r --- �C j Address: //V ,e M 1 j
?hone Number: (EM): (WK):
Time for Water locate
Check for: Ac curacy teat:_ Maw Leak: Check rater premium: Initial maw relocation inspection its-mad
_
1.Backflow Insn. 2. Retai.r, 3.Maintenance l•Cther
Backflow Insp. A.Main Line A.fps A -Line Locate
B.Valves B.water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
Reason for failure: A. Electrolysis B. New construction C. Poor installation.
�. D. Other
5. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape Tape D. Lights E. Other (), /
Request for Serviceman: . P _�' ./4, 9, ��/ . 7Z l -uC�r "
Requ C %0 f
Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Fstimus :: GPM :ire plug flushing Total Gallons
3.was Water Metered: Yes No
_.Was Customer Notified: Verbally DOORIIDYOCKER
Vehicle /Equipment Used
I
3.-` Meter Change Out: Unit # Hiles firs Equip 4l `/ c J
Old Meter # 9 t 7 7 ✓�' Readingt /( �6 . 7 /` Z 0 . .7/`0
I
3. New Meter# Z l0 3(J 7 Reading D DOUG' 3
l/
:Lad Meter Size /Type: J� u .,,W° --42:-New Meter Size /Type 5 i' ' �W::;:
I. Type of work performed or findings: z� .
l /,`%/ice/
9.If mainline or deep service repair, describe type of pipe or service line and condition:
AO
10.Manhours: / 7 Crew members: ___
11.List Materials Used:
12.It 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 trips to do task? Signature