0330 WATER
issued finished s �'.���� ,,! / h,•L Grid map
Name: , Address: z-` 1 ) ,Vt
Phone Number: (ffi{) : (yam)
Time for Water locate
Check for: Accuracy wt_,.. Mar La! _ Crock ewe plums: %tidal mart gifoe,doa eopa$oq__ Ra-
1.eackflow Ipso. 2. logic 3.Maintenance 4.StAtc
Backflow Insp. A.Kaia Line A.Pusps A.Line Locate
B.Valves 8.Water Tower 8.Znspectioa
Bkflaw Cert.Date C.service Line C.3asples C.Tap
• D.Sydrants D.Zquipmsnt D.Excavation
Rs -Cert. Date E.Safsty
S. Reason for failure: A. Electrolysis 8. New construction C. Poor installatio:
6. List of sat D. Other
sty equipment at site if applicable:
A. Barricades D. Cones C. Tape D. Lights E. Other C,
Request for Serviceman: licto malt_
7.2f Heter /service Leak: Classify - City: Customer: �
A.Water Loss (Eramar.): GPM. ,tire plug flushing Total Gallons .
B.Was Water Metered: • Yes No
C.Nas Customer Notified: Verbally
Vehicle/Equipment treed
•.rf Meter Change Out: Gait # Niles firs Equip
A.OLd Heterf `? L= am' , Reading 3 I fix, ///
8. New Meter# Reading
•
r
C.Old Meter Size /Type: ?1 ' )t v /Ir'kL ' 1 , D. New Mater Sias /Type , , ) < ‘I
E.Type of work performed or findings:
9.1f mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ' + - Crew members: =
11. Gist Materials Used:
12.2e you had an accident /incident while performing this request- DLd you report its yes or nc
13 -Water Utilities meter inspection: pass or fall
14.Hcw many trips to do task?