Untitled (9) WATER
Issued finished lb °
loyee ,rid map
Nam*: Li i r � N Address: (PG) (7 f:r
Phone Number: (HM): (WX) :
Time for water locate
Check for: Amstar! tor__ Maa r Leak Cheek vow possum tail maw cetoeadoa isq«eoq_ . Bread
I.eaekflow Inso. 2. gm:air, 3.
Backflow Insp. h. A.
a Line S =
3. Vale 3
Tow
s 3' fps s A. Line Loch
8.sater er .Enspection
• Bkflow Cert.Date C.Service Line C.Sampiea C.Tap
Re - Cart. Date • D.Bydraats D.squipment D.Excavation
E.Safety
5. Reason for failure: A. electrolysis B. New construction C. Poor iastallatic
D. Other
S. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman: _ 1 AAr 0 4- 0/0 lu
4- J '2.--- . .
7. If Meter/Service Leak: Classify - City: z:: ::..---_ Ccstomer: __
a.Kater Loss (eir-): GPM lire plug flushing __ Total Gallons .
B.tsas Water Metered: • Yes ___ No
C.Nas customer Notified: Verbally DOCUNO
Vehicle/3quipment geed
$.If Meter Change Cut: / Omit # Niles Ers Equip
A.O1d Meter# S/( Ft‘ Z Readin v C1 ` S 7 2 9X 2 -?)
1
,' ?.52 �� fi
B.New xeter ) Reading
C.Old Meter Sise /Type: D. New Meter Size /Type
E.Type of work performed or fiadiags:
9.rf mainline or deep service repair, describe type of pipe or service line and condition:
21
10.hanhours: _ Craw members: - ..
•
1L.Gist Materials C.
1-4.4.
1.2.r:' you had an aceLdent /LncLdent while performing this --lest- OLd you report Ltt yes or n
13-Water tJtilLttes setae inspection: pass or fall
t1.Ifcw many trips to do task?