1209 WATER
Isausd — — Finished G Employeer/(Xft- /j Grid map
Name: Address: / „
?hone Number: (BM): (WE) •
Time for Water locate
Check for: Accuracy wt:__ Maur leak Check vatar pressure: Initial meat talocatiott impaction Pa-mad
1.Backflow Inem. 2. a 3.Haintenance l.Other
Backflow Insp. A.Main Line A.Pumps A.Lins Locate
B.Valves B.Water Tower B.Inspsction
Bkflow Cert.Date C.Serrice Line C.Samples C.Tap
D.Nydrants D.Equipment D.Excavation
Re -Cert. Date • E.Safety
S. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman:
Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Fs ima":: GPM Fire plug flushing Total Gallons
;.was Water Metered: Yes No __
:.Was Customer Notified: Verbally DOORAMCKWER
Vehicle /Equipment Used
3.If Hater Change Out: Unit # Miles Firs Equip
A.Old Meter # f7 7 b Readin g / 3 ?' el ° - 2ae /7/ 2'7 or
1
3. New Meter # /
, ; Z Reading(Y . '6
C.Old Meter Size /Type: //
! -° Meter Size /Type � Z ../ -�c .. / .
E.Type of work performed or findings: 51' 77/ IV?
//f d/
s
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.IJanhours: 3/4/ Crew members: _'
II.List Materials Used:
12.11 you had an accident /incident while performing this request. Did you report it? yes or no
13.Water utilities deter inspection: pass or fail
14.Aow many trips to do task?
Signature