1215 WATER
r
Is auad Finished 7L- lJ Employe., /"j -�t Grid map
Name: , Address: /G C
?hone Number: (82I) : (WX):
Time for Water locate
Check for: Acwncy we:_ Maur Leak Mack water pressure: Initial mater relocation inscrectiott Ra-reed
1.Backflow Inez. 2. a 3.Maintenance d.Other
Backflow Insp. A.Main Line A.Pumps A -Line Locate
B.valves B.Water Tower e.Inspection
•
Bkflow Cerr.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
E. Reason ft: failure: A. Electrolysis 8. New construction C. Poor installation.
D. Other
n. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:, .
Meter /Service Leak: Classify - City: Customer:
A.Mater Lass ! mua:: G ?M ?ire plug flushing 'Total Gallons
3.Was Water Metered: Yes No
:.Was Customer Notified: verbally DOORENOCOMK
Vehicle/Equipment Used
3.If Meter Change 1,
Out: /� �7 // 4g' / �/ Unit # Miles Ere Equip 4
A.Old Meter, 6 effi / �/ i" Reading L/ /// 7 Z t ,
G/ 7 I
3. New Neter# 2 ! G 7 � & Z Reading
y e r/ /27/4"4f4/ ' X =Id Meter Si:.e /'1yge : .....D: ��New Meter Size/Type ����� ..
E.Type of work performed or findings: 9 77 ■ � /
/9
9.If mainline or deep service repair, describe type of pipe or service line and condition:
1G.4anhours: 9/y Crew members:
P LL.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it7 yes ar no
12.Water Utilities meter inspection: pass or fail ..
14.How many trips to do task? ,
Signature