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1214 WATER l Issued 'finished / 7 7l Employee h i Grid map Name: A ddress: Q / ���� G'O/"1°°. ?hone Number: (BM): (WK) : _ Time for Water locate Check for: Accuracy Inc_ Maar Lea__ Clack water preaauce : Iaitiai mere[ eslocation impectio _ Re-read _ 1.Backflow znso. 2. Jeoair 3.Mainteaance 4.Other Backflow Insp. A.Main Line A.Ptmsps A -Line Locate B.Valves B.Water Tower B.2nspection Bkflow Cert.Date C.Service Line C. Samples C.Tap D.Hydrants D.Equipment D.Excavation Re -Cert. Date E.Safety 1. Reason =or f ailure: A. Electrolysis B. New construction C. Poor installation. D. Other 6. List of safety equipment at site if applicable: A. Barricades 3. Cones C. Tape D. Lights E. Other Request for Serviceman: 7.1_ Meter /Service Leak: Classify - City: __ Customer: A. Water Loss Meimue: GPM Fire plug flushing Total Gallons S.Was Water Metered: Yes No :"..was Customer Notified: Verbally Vehicle /Equipment Used 3. :f Meter Change Out: Unit / Unit # Hiles Firs y Equip A.Old Meter. Q 7�J Z / Readin /l� 0o � ij // Z/ 7 f •ee ' 3. New Met er# Z ya77'` Reading ©a�W Cold Meter size /':yge : $ /i l ��i _ - -D: -New Mete Size /Type /t .e o ' X- .. E.Type of work performed or findings: /Gv/e 5 e Z-// 6' / ' i 9.If mainline or deep service repair, describe type of pipe or service line and condition: 10 . 4anhours : , 7/9 Crew members: / II.List Materials Used: 12.21 you had an accident /incident while performing this request. Did you report it? yes er Ao 12.Water Utilities meter inspection: pass or fail 14.How many tripe to do task? Signature