1125 WATER
Issued /1/ Finished Employee Grid map _
Name: Patti C Address: � 6 / 1 t • 4
Phone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy test _, Meter Leak: Cbeck water pressure: Initial meter relocation inspection__ Re -read
1.Backf low Insp. 2. Repair 3.$aintenance `.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Eydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis 8. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. nes C. Tape D. Lights E. Other
Request for Serviceman (� � .
7.If Meter /Service Leak: Classify - City: Customer: •
A.Water Loss (Eeimate): GPM Fire plug flushing Total Gallons
B.Was Water Metered: • Yes No
C.Was Customer Notified: Verbally DOORKNOCKER
Vehicle/Equipment Used
8.If Hater Change Out: I Unit # Miles Mrs Equip
A.Old Meter 0` S O �( �Reading?S / 0 VI - ) O ,5 - 70
0
B.New Meter# ein�Y Reading V
l �
� / A t
C.Old Meter Size /Type: D. Ne w Meter Size /Type \ l �J "/
y /17
E.Type of work performed or f'-dings:
7 /.: 4 ,t 1
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ( Crew members: `
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail I'
14.How many trips to do task? ? C-,
Signatur �