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0329
WATER 2aswd linishad 'Z R mp L oyf �� Grid map Name: / r n A,ddrese : `{0 S /7 U ✓l `f" e ✓z � K. r Phone Nuunbtr: (ffit) : (WX) : (J Time for Warier Locate Check tor: Aawu7t L,.b___ Cmekvnvepe ?idd nieseieai pain _- La. 1.1ackflow Insn. 3. 1 3 .NaLalimags C Backllow Insp._. A.tea Line s.Valvee s. ter Tower a;L� Lees akflow Csrt.Oate_, C.service Line C.Saaples C.Ta • Re -Cart. Date D.Nydrants D.Sguipm.nt D.Exeavatio N. Safety S. Reason for failure: A. slectrolysis B. New construction C. Poor ia.tallat Other i. List of safety equipment at site if applicable: 0. A. Barricades 1. Cones C. Tape D. Lights =. Ocher Request for Serviceman: Wa, k� YIZe P �Qi r • 7.If xeter /Service Leak: Classify - City: Customer: ___ a.sater Loss tumor.): GPM Firs plug flushing _ Total Gallons • _ S.fias hater Metered: • Yes No __ C.Nas Customer Notified: Verbally DOOMK OC IR ____ Vehicle/Equi:es:t Used 1.If Meter Change Out: Unit # Riles Mrs Equip x.OLd Mater# 030 9 (a `( Reading 30 �9S )1 ? n a.New Meter! Z 3 . ©\ (O Reading D , C.OLd Meter Size /Type: / r V Y I� E'A / r 0 . Xe t linter rise /Type QSJE►e�e�"e'� qv a Z.Typ• of work performed or findings: 9. If mainline or deep service repair, describe type of pipe or service line and conditions lO.Hanhcuts: 1. Croy members: Z �, 11.L:at Materials Used: La' L1.I: you had an accident /LncLdent while performing this request. OLd you report Lt? Yes or 13.ua;er tJtLLLciee meter inspection: pass or fail 11.14cw many trip. co do tai's;;