1221 / WATER
Issued Finished Employee 3 � ,:�� Grid map
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Name: address: G r p j , i ./1 "/ GI
?hone Number: (ED): (WX) :
Time for Water locate
Check for: Accuracy snc _ Maa L.ak:_ Cluck water ptsaautc _ Initial meta nlocatioa impacting ltresad
1.19ackflow Ins?. 2. BlEALE 3.Maintenance I.Ot)1er
Backflow Insp. A.Main Line A.Pumpa A.Line Locate
B.Valves B.Water Tower 3.Inapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cent. Date E.Safety
1. Reason fcr failure: A. Electrolysis R. New construction C. Poor installation.
D. Other
o. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.If Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Eaimm : GPM Fire plug flushing iota/ Gallons
S.Was water Metered: Yea No
C. Was Customer Notified: Verbally DOORENCKMONt
Vehicle /Equipment Used
3.If Meter Change Out: Uni t # Miles Firs Equip
i.Old Heter # e z Reading /f‘ .5 i ® ` /v / 3 f
3. New Meter# Z// 1- ' Reading 0
C.Old Meter Size /Type: 2 / / �/ '..._D: - •New Meter Size /Type / /7/,5/./ ..
3. Type of work performed or findings: /'? 2 e 'il
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours: , 3�/�', Crew members: ,
II.Liat Materials Used:
12.11 you had an accident /incident while performing request. Did you report it? ye• or no
13.Water Utilities meter inspection: pass or fail
14.Row many trips to do task?
Signature