1215 . WATER
to ee, 47X11 Grid map
Issued Finished Emp y
Address: Name: '�
?hone Number: (BM): (WX):.
Time for Water locate
Check for: Manic. us:_ Meter Lea___ Cb.ck enter pressure: Initial ewer relocation ;arp«tio _ Pa ad
1.Backflow /nat. 2. Revair 3.4aintenance 4., her
Backflow Insp. A.Main Line A•Pumps A. Locate
B.Valves B.Water Tower B.I spection
Bk_low Cert.Date C.Service Line C. Samples C.Tap,
D.Hydrants D.Equipment D.Excavation
Re Date E.Safety
R eason f failure: A. Electrolysis B. New construction C. Poor installation.
• . tr D. Other
a. List of safety equipment at site if applicable:
A. 3arricades 3. Canes C. Tape D. Lights E. Other
Request for Serviceman: .
7.T.1. Meter/Service Leak: Classify — City: Customer:
A. Water Loss (E imu.s: G ?M ?ire plug flushing Total Gallons ___
3.Was Water Metered: Yes __ No ___
C. Was Customer Notified: Verbally ____ DOORZEMKN R
Vehicle /Equipment Used
3.1! Meter Change Out: ...., # Miles Urs Equip
4,, / (2_(d 2"•�Z. lo
Oid Meter �(/��7 Reading /) � (
3. New Meter# ? -/ e7 � s Reading ( 1
.Old Meter Sipe /'- 'yge',
, eC / /e • • / ----D.: -New Meter sue /Type V 5 ,� / .
3.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
1G . Kanhours : , Art,' Crew members: ,_f
,L1.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
12.Water Utilities meter inspection: pals *or fail
14.Aow many trips to do task? Signature