0301 WATER
Usued 2/
Finished y / Zmployee____4 / 1- Grid map
Name : Z.---
O C Z— ___/241 7 ; '
Phone Number: (H4): (WK)•
,
Time for Water locate
Check for: Meurer! we:_ Mao Laak Meek riser pressure: loins: seta n:oeaioa io mak s lto-read
1.Backflow Inen. 2. 3.Maintenance 4.2Sher
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower 3.Inspection
Bk_low Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re-Cert. Date • E. Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
a. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman: -
Meter /Service Leak: Classify - City: • Customer:
•r
A.Water Loss (Sawmills:: GPM Fire plug flushing Total Gallons
S.Was Water Metered: :es No
C.Was Customer Notified: Verbally
Vehicle /Equipment Used g,
3.Lf Hazer Change Out: Unit # Miles Mrs Equip
A.Old Meter # 7 7657" " Reading 3 -/ Z 2 /� / 2_ 7. ,,.
W;77!2- i
S.New Mete-4 & Reading
C.Old Meter Size/Type: / g .-D: Stew Deter S£ze /Type % � /, •
(.Type of work performed or findings: X ,, , �;-�/ .
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours : V / Crew members: _/
II.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities aster inspection: pals or fail .
14.Row many trips to do task?
Signature