1221 WATER
Issued Finished / Z/Z/ Employee i ,4 i'�7 Grid map
. Address: 5 3 Z ,J o% i /
Name:
?hone Number: (BM): (WX):
Time for Water locate
Check for: Mousey, Inc_ Meter Lea Cheek moat press= Initial meter teloauon imgatio _ R.- ad
1.Backflow Intro. 2. Reoai_; 3.faintenance 4.2ther
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Weter Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Semples C.Tap
D.Eydrants D.Equipment D.Excavation
Re -Cert. Date • E.Safety
Reason far failure: A. Electrolysis B. New construction C. Poor installation
S. D. Other
6. 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: _
A.Water Loss (ficimuei: GPM ?ire plug flushing Total Gallons
S.Was Water Metered: Yes No
:.was Customer Notified: Verbally DOOBENCIMUME
Vehicle /Equipment Used
3.I.1. Meter Change Out: Unit # Miles Firs Equip
�7 ' 5 /3 22 7 iiV 272 >,
:..Old Meter # / �/ Reading
Z�'�i3�' /7
.New Meter# Reading
4.
Meter Sire/Type: / / D : New Meter Size /Type S�j !���
:7-Type of work performed or findings: _ ✓ l/ / f / ,'" 49Z4/--
.6.12=
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . 4anhours : 1 / 4 ✓ Crew members: __,j
f Il.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
II.Water Utilities meter inspection: pass or fail .
I4.Hew many trips to do task? ,
Signature