1217 � WATER
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Issued t /�l J Finished Employee /' / M? " Grid map
Name: Address: f nr 4 //
?hone Number: (BM): (WK): •
Time for Water locate
Check for: Accuracy tesc_ Man Tway Cluck water pressure: Initial mesa nlocuion impaction Raitad
1.Backflow Inst. 2. Retain 3.4aintenance i.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.tnspection
Bkflow Cert.Date C.Service Line C. Samples C. Tap
D.Hydrants D.Equipment D.Excavation
Re -Ceti. Date E.Safety
S. Reason f ^r = ai?ure: A. Electrolysis 3. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. 3arricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.1f Meter /Service Leak: Classify - City: Customer:
.. Water Loss (From.:: GPM Fire plug flushing 'Total Gallons
3.Was Water Metered: Yes No
_.Was Customer Notified: Verbally DOOKENOCEER
vehicle /Equipment Used
3.1% Meter Chan Out: Unit # Miles Hrs Equip
g ' / /J/ d/ ry sf" /- /i Z � >7.
:,.Old Heterr Reading 4
3. New Meter # 2 . A 7 Reading .,
C.Old Meter Size /Type: i $`� ���d- -ileac Meter Size /Type ) / /7�S - ..
E.Type of work performed or findings: 5 /A�`W��� 0
/V7;(
9.I: mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours : 3/ y Crew members: /
P I1.List Materials Used:
12. If you had an accident /incident while performing this request. Did you report it? yes or no
13.Watsr Utilities meter inspections pass or fail ..
14.Rew many trips to do task?
Signature