1209 WATER '
Issued Finished /i Employes � � Grid map
Names Address: /5/ �"' ,, � /,44
?hone Number: (am): ( )
Time for Water locate
Check for: Amon? vs:_ Mew Laic_ Mack water premiuee : Initial maa a koeation cc O _ Rrts+d
1.Backflow Inso. 2. amis. 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
E. Reason for failure: A. Electrolysis B. New construction C. Poo r. installation.
O. List of safety equipment at site it applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman: .
Meter/Service Leak: Classify - City: ____ Customer:
A. Water Loss (Euinw' : GPM, Fire plug flushing ___ __ Total Gallons __
S.Was ware: Metered: Yes No
2.Was Customer Notified: Verbally _ DOORIENOCRSR
Vehicle /Equipment Used
3.If Meter Chang Out: / Unit # // Miles Hrs Equip
j 0 ( g / 7 '6 c '( Reading() 7 / `- G/ «7 /, �,/ /& L 7G
f I er
A.Old Heterr //11 i
3. New Meter, /v) ( / '7 Reading /.' /' 6''01
.Old Meter Si:.e /Type: 5// / e C 7 / 0 k -D : . New Meter Size /Type
�
3. Type of work performed or findings : 5 i � it t 1f/ /` 1j /(
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Ianhoure: _ Crew members: 2
, LL.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 inspections pass or fail
14.How many trips to do task? Signature