1214 WATER .
Issued Finished /Z / Y Employee , �l ` e Grid map
Name:
Address: .7G v
?hone Number: (BM): (WX) :
Time for Water locate
Check for: Accurst: tae:_ Maar Loeb_, Mock water pressure: Initial matt relocation iinpectio _ Rs -tend
1.Backflow inen. 2. Revai.: 3.faintenanee 4.Other
Back_low Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bk_low Cert.Date C.Service Line C.Samples C.Tap
D.ffydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
Reason for failure: A. Electrolysis B. New construction C. Poor installation
�. construction D. Other
o. List of safety equipment at site if apolicabls:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.!! Meter /Service Leak: Classify - City: Customer:
A. Water Loss a:Aimaui: GPM ?ire plug flushing total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: verbally DOORENCIOOCR
Vehicle /Equipment Used
3.If Meter Chang Out: 7 Unit/ Miles Firs !quip
l f �fff 7 Reading 4 / / �'/ /� 2 /t t�
A.Old Meter;=
3. New Meter# 2 ` l�� G/ 1 J" ` Reading_ &'
eter Sire _ e:f
7,1.4'z',•/'
/ 4 " 324 ' D New Mater Size/Typo 1 7$ ; /.�,
...Old M /''Yp
Type of work performed or findings: 1/ e� r dA Ae
9.If mainline or deep service repair, describe type of pipe or service line and condition:
1O.Ianhcurs: ,3 /V Crew members: _f
p 11.List Materials Used:
12.1f you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task? , •
Signature