1219 . r .
WATER / /� ' .
Issued _ _ Finished / /. l/ Employee / (,�(� •
Grid map
Address: / --;- °
Name:
?hone Number: (mm): (WX) :
Time for Water locate
Check for: Accuracy taw_ Masr Iwat_ Cheek inter press um Initial maer relocation impaction Rr:s d
1.Backflow Inso. 2. Reoair 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 -Cent. Date
t 'Reason for failure: A. Electrolysis B. New construction C. Poor installation.
S. construction „D. Other
o. List of safety equipment at site is applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman: .
Meter/Service Leak: Classify - City: • Customer:
Water Loss (Eaimates: GPM ?ire plug flushing Total Gallons __
3.was Water Metered: Yes No
...was Customer Notified: Verbally DOORKNOCUMK
Vehicle /Equipment Used
3.I= Meter Change Out: Unit
C/ Unit # Hiles Bra quip
A.Old Meter # �) 2 Readifl/ J //•' Gy G2.
2 I
3.New Meter # OY'/ ZZY Readinc��
C.Old Meter Sire /_ e: X 4 -A -- -D: w Meter Si /Type % � � � "
formed or findings: ' 1�� /`
/� ��
...Twe of work per_ q //'/'
C
9./1! mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: ,7/r Crew members: ,
* II.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
14.1low many tripe to do task?
Signature