0331 WATER
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Nam*:
Address: ZOO J ES
Phone Number: (Hi):
Time for Water Locate
Check for: Aria: q let, Wise Lsalc__, Chest vest Pe*+ = L'ud mat idosadoe iseenioa___ Rollo
1.eackflow rnsn. a. g 3.
Backf low Insp._ A.�g Lino d •t.
B.Valves s.Ra Tower B. a Lois
Rlkflow Cert.Date C.Survice Line C.Sas�ples C.Tap��
• Re Date • 0.lydrants D.squipmsnt D.Exeavatio.
:.Safety
5. Reason for failure: A. /electrolysis B. New construction C. Poor instaliat.
S. List of safety equipment at sits if applicable: D. other
A. Barricades 1. Caws C. Tape D. Lights Z. Other
Request for Serviceman: 4 4 ti ►'le t-C Q- e c ` 4
•
7.If Meter /Service Leak: Classify - City: ____ Customer: •
A.Water Loss ('aoeme): GPM Pirs plug flushing Total Gallons ___ .
B.Was Prater Metered: • Yes _____ No
C.Was Customer Notified: Verbally DOOIDOSpCZelt
Vehicle/sq:sipeent Mod
1.2f Meter Change Out: Unit # Miles Ira Equip
A.OL4 Mater# (oo S Z Z Reading e ' ts - C)
8. New Meter, 2 -4r) 3-e Reading O
C.01d Meter Sise /Type: AAGige.n 1'1�e P,c_ s lc D. New Mater Sts. /Type V»J i tMet &FZ s/'
E.Type of work performed or findings:
9.If mainline or deep service repair, describes type of pipe or service lin. and condition:
1a.Hanhours: 1 I - t_ Crew members: 1 - -
lL.C.Lit Materials Used: cbtAr D 1
11. re you had in accident /LneLdent while performing this request. OLd you repart itt yes or
L3.ua:.r UeLLLCLe• s•tec LnapectLon: vase or fall
L1.ficw many trips to do task/