1027 WATER
Y
Issued/ Finished Employe• Grid map
/
Name: `it 9lk L,. G, Address: ��� !
?hone Number: (HM): J (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak: Check water prssauts : Initial meter relocation inspection Re-read
_
1.Backflow /nor). 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
Reason fcr `failure: A. Electrolysis B. New construction C. Poor installation
'. D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape D. ( ^ Lights E. Other
Reauest for Serviceman i 0 `1 .' ./ �p � k''' 1
,;t # S/09a9 /0 3 - 1 b c ?4'
',.If Meter/Service Leak: Classify - City: Customer:
A.Water Loss (Fstimam:: GPM Fire plug flushing Total Gallons
S.Was Water Metered: Yes No
_.was Customer Notified: Verbally DOORIQ1OCIER
Vehicle /Equipment Used
3 . If Meter Change Out: / Unit # Hiles Hrs Equip
( W:2 / Reading() add /V (.t T �?� ? 0
A.Old Meter,
:.New Meter #2 ) f d Reading 0
S/' "
C.Old Meter Size /Type: /f �
/ ) D. New Meter Size /Type ik
:.Type of work performed or findings: .
g-OAJ ' _ 4, .t_i, , GM _ Ai, , .- , + lotd
9.If mainline or deep service repair, describe type of pipe or service line and condition:
1O.Manhours: 1� Crew members; ---_1___-_ __,�
11.List Materials Used:
12.2E you had an accident /incident while performing this request. Did you report it? yes or no
13.Watsr Utilities meter inspection: ass or fail Oa r
14.How many tripe to do task?
Signature c'll