152 Glenwood WATER . •
�( Issued __ Finished Employee / '��" /{ � Grid map
1 �__
Name:
Address- /1 Z G 7,4. /e, e -,, ,
?hone Number: (BM) : , (Wit):
Time for Water locate
Check for: Ascuncy laic_ Man Laal _ meek water pressure: Initial mat mkcssies kopecks A+-read
1.Backflow Insp. 2. MEAL: 3.Maintenance 4•Other
Backflow Insp. A.Hain Line A.Pumps A•Lins 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
I. Reason for fa -lure: A. Electrolysis B. New construction C. Poor installation.
o. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.If Meter /Service Leak: Classify — City: • Customer:
;,.mater Loss MaWmtat: GPM ?ire plug flushing Total Gallons
3.was Water Metered: Yes No _______
_.Was Customer Notified: verbally _ DOORICNOCCER
Vehicle/Equipment Used
3.1! Meter Change Out: Unit # Hiles Hrs EqiiP
A. Old Meter 7? ? , S� 7/5 77Reading G / / 6 G f f L/ 7 A` ll -/I L Y ?" > f er
1
3.New Meter # ZrG Z U Reading aPe a eV
^.Old Meter Site /'.ype: - / 5 / '✓ - D = New Meter Size /Type
I . Type of work performed or findings: h/,
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours : IA/ Crew members: Z
V 11.List Materials Used:
12. If you had an accident /incident while performing this request. Did you report it? yes or n°
13.Water Utilities enter inspection: pass or fail
14.How any trips to do task? Signature